Provider Demographics
NPI:1023136512
Name:BOLAND, SUSAN KAY (PA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:BOLAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:KAY
Other - Last Name:PENDELL-ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:300 NORTH WASHINGTON STREET
Practice Address - Street 2:DARIEN MEDICAL CLINIC
Practice Address - City:DARIEN
Practice Address - State:WI
Practice Address - Zip Code:53114-1534
Practice Address - Country:US
Practice Address - Phone:262-882-1151
Practice Address - Fax:262-296-1195
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001543363A00000X
WI2122-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1023136512Medicaid