Provider Demographics
NPI:1114446028
Name:BOLLINGER, RODERICK WAYNE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:WAYNE
Last Name:BOLLINGER
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5708
Mailing Address - Country:US
Mailing Address - Phone:660-951-1091
Mailing Address - Fax:
Practice Address - Street 1:115 W BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5708
Practice Address - Country:US
Practice Address - Phone:660-951-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017032883363LF0000X
MO2011036360363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily