Provider Demographics
NPI:1508303009
Name:BOLING, VINCENT BLAKE (MSNA, CRNA)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:BLAKE
Last Name:BOLING
Suffix:
Gender:M
Credentials:MSNA, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 CHATTANOOGA AVE
Mailing Address - Street 2:APT. A124
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8884
Mailing Address - Country:US
Mailing Address - Phone:706-463-6325
Mailing Address - Fax:
Practice Address - Street 1:801 CHATTANOOGA AVE
Practice Address - Street 2:APT. A124
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8884
Practice Address - Country:US
Practice Address - Phone:706-463-6325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN219675367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered