Healthcare Provider Details

I. General information

NPI: 1053726653
Provider Name (Legal Business Name): NICHOLE BOISVERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

IV. Provider business mailing address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

V. Phone/Fax

Practice location:
  • Phone: 925-370-5000
  • Fax:
Mailing address:
  • Phone: 925-370-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA142097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: