Provider Demographics
NPI:1790954501
Name:BOLYARD, JASON A (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:BOLYARD
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:PO BOX 504407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4407
Mailing Address - Country:US
Mailing Address - Phone:816-502-7000
Mailing Address - Fax:
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-389-6030
Practice Address - Fax:816-389-6034
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005029853367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SRNAOtherSTUDENT
MO2005029853OtherLICENSE