Healthcare Provider Details

I. General information

NPI: 1881178655
Provider Name (Legal Business Name): SIERRA BOLLES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SIERRA BURT PA-C

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 11/13/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3336 SOUTH 4155 WEST #102
WEST VALLEY UT
84120
US

IV. Provider business mailing address

3336 SOUTH 4155 WEST #102
WEST VALLEY UT
84120
US

V. Phone/Fax

Practice location:
  • Phone: 801-964-3925
  • Fax:
Mailing address:
  • Phone: 801-964-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10977713-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10977713-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: