MEDICARE: BOLA ELEMUREN MD. PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA01547	TX
2	207Q00000X	Family Medicine Physician	K4050	TX

General Provider Information

NPI Number	:	1598959389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLA ELEMUREN MD. PA

Provider Business Mailing Address
First Line	:	740 S AMY LN
Second Line	:	STE 101
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-1343
Country	:	US
Telephone Number	:	254-699-8521
Fax Number	:	254-699-8528

Provider Business Practice Location Address
First Line	:	740 S AMY LN
Second Line	:	STE 101
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-1343
Country	:	US
Telephone Number	:	254-699-8521
Fax Number	:	254-699-8528

Authorized Official
Title or Position	:	OWNER
Name	:	DR. IYABO BOLA ELEMUREN
Credential	:	M.D
Telephone Number	:	254-699-8521

Provider Enumeration Date	:	09/05/2007
Last Update Date	:	01/10/2012

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