Provider Demographics
NPI:1760473722
Name:BOLES, AMY L (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:BOLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN STREET MANKATO CLINIC LTD
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1421 PREMIER DRIVE
Practice Address - Street 2:MANKATO CLINIC AT WICKERSHAM CAMPUS
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP64495OtherHEALTH PARTNERS
MN133219OtherUCARE
MN2443242OtherAMERICA'S PPO
MNNA2951047341OtherPREFERRED ONE
MN01-23833OtherMEDICA
MN54093OtherSANFORD HEALTH PLAN
MN057753700Medicaid
0724203OtherIOWA MA
MN523P5BOOtherBCBS
MN54093OtherSANFORD HEALTH PLAN
MNNA2951047341OtherPREFERRED ONE