Provider Demographics
NPI:1164415501
Name:BOLYANATZ, MARYA MEI (FNP)
Entity Type:Individual
Prefix:
First Name:MARYA
Middle Name:MEI
Last Name:BOLYANATZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:117 WEST BUNNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-543-4043
Mailing Address - Fax:805-543-7640
Practice Address - Street 1:1250 PEACH STREET
Practice Address - Street 2:SUITE A
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2837
Practice Address - Country:US
Practice Address - Phone:805-543-4043
Practice Address - Fax:805-543-7640
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB236600OtherMEDICARE ID