Provider Demographics
NPI:1033216569
Name:BOLES, MICHEAL E (PHD APRN BC)
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:E
Last Name:BOLES
Suffix:
Gender:M
Credentials:PHD APRN BC
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 427
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TN
Mailing Address - Zip Code:38551-0427
Mailing Address - Country:US
Mailing Address - Phone:931-243-3860
Mailing Address - Fax:931-243-4607
Practice Address - Street 1:PO BOX 388
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TN
Practice Address - Zip Code:38551-0388
Practice Address - Country:US
Practice Address - Phone:931-243-3860
Practice Address - Fax:931-243-4607
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4343158OtherBCTN
TN1511326Medicaid
P06888Medicare UPIN
TN4343158OtherBCTN