Provider Demographics
NPI:1477529485
Name:BOYLE, CHARLES RICHARD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RICHARD
Last Name:BOYLE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 GREENLEAF RD
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-2223
Mailing Address - Country:US
Mailing Address - Phone:507-334-9485
Mailing Address - Fax:
Practice Address - Street 1:200 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6339
Practice Address - Country:US
Practice Address - Phone:507-332-4864
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 139390-7367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS58804Medicare UPIN