Provider Demographics
NPI:1053845495
Name:BOULIGNY, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:BOULIGNY
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 1:3822 CRESWELL AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-1265
Mailing Address - Country:US
Mailing Address - Phone:512-964-4139
Mailing Address - Fax:
Practice Address - Street 1:WAKE FOREST BAPTIST MEDICAL CTR
Practice Address - Street 2:MEDICAL CENTER BLVD.
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:512-964-4139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program