Healthcare Provider Details

I. General information

NPI: 1083190649
Provider Name (Legal Business Name): WYATT JAMES BOLES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W BLDG A
PROVO UT
84604
US

IV. Provider business mailing address

1055 N 500 W
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-812-5033
  • Fax: 801-812-5034
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7685502-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: