Provider Demographics
NPI:1184213555
Name:BOULOM, ANITA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:
Last Name:BOULOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 UNIVERSITY BAY DR APT 315
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2268
Mailing Address - Country:US
Mailing Address - Phone:469-348-5497
Mailing Address - Fax:
Practice Address - Street 1:3400 DEERFIELD DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-3557
Practice Address - Country:US
Practice Address - Phone:608-314-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5192-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant