Provider Demographics
NPI:1083720643
Name:BOLLOM, SUSAN LAYNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LAYNE
Last Name:BOLLOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:LAYNE
Other - Last Name:ROLLINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BOLLOM: IS MAIDEN
Mailing Address - Street 1:390 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:27299-9049
Mailing Address - Country:US
Mailing Address - Phone:704-638-9000
Mailing Address - Fax:
Practice Address - Street 1:1601 BRENNER AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2515
Practice Address - Country:US
Practice Address - Phone:704-638-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant