Healthcare Provider Details

I. General information

NPI: 1225390719
Provider Name (Legal Business Name): PATRICK LYNN BOLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 HIGHWAY 80 E
CLINTON MS
39056-5252
US

IV. Provider business mailing address

815 HIGHWAY 80 E
CLINTON MS
39056-5252
US

V. Phone/Fax

Practice location:
  • Phone: 601-910-3004
  • Fax:
Mailing address:
  • Phone: 601-910-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLL34725
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPGY..202111
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number24316
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: