Provider Demographics
NPI:1023182409
Name:BOISVERT, BRIAN K
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:K
Last Name:BOISVERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589
Mailing Address - Country:US
Mailing Address - Phone:315-589-9391
Mailing Address - Fax:315-589-7418
Practice Address - Street 1:5106 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589
Practice Address - Country:US
Practice Address - Phone:315-589-9391
Practice Address - Fax:315-589-7418
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02556018Medicaid