Healthcare Provider Details

I. General information

NPI: 1396721429
Provider Name (Legal Business Name): BRIAN P BOLEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 2ND ST
FORT LUPTON CO
80621-1745
US

IV. Provider business mailing address

203 S ROLLIE AVE
FORT LUPTON CO
80621-1508
US

V. Phone/Fax

Practice location:
  • Phone: 303-857-4388
  • Fax: 303-857-1179
Mailing address:
  • Phone: 303-286-4560
  • Fax: 303-286-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1629
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: