Provider Demographics
NPI:1083190649
Name:BOLES, WYATT JAMES (DO)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:JAMES
Last Name:BOLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2912 S TACOMA PL
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-2880
Mailing Address - Country:US
Mailing Address - Phone:801-472-3209
Mailing Address - Fax:
Practice Address - Street 1:216 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6300
Practice Address - Country:US
Practice Address - Phone:509-221-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program