Provider Demographics
NPI:1104988070
Name:BOLES, TONYA JOY (PAC)
Entity type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:JOY
Last Name:BOLES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:BATTIEST
Mailing Address - State:OK
Mailing Address - Zip Code:74722-0180
Mailing Address - Country:US
Mailing Address - Phone:580-241-5294
Mailing Address - Fax:580-241-5739
Practice Address - Street 1:6026 BATTIEST PICKENS RD
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-5033
Practice Address - Country:US
Practice Address - Phone:580-241-5294
Practice Address - Fax:580-241-5739
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200026970AMedicaid
P67023Medicare UPIN