Healthcare Provider Details

I. General information

NPI: 1225289689
Provider Name (Legal Business Name): DANIEL P BOLL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 S 6TH ST
BRAINERD MN
56401-3054
US

IV. Provider business mailing address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

V. Phone/Fax

Practice location:
  • Phone: 218-828-7100
  • Fax:
Mailing address:
  • Phone: 320-762-1511
  • Fax: 320-762-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10494
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: