Provider Demographics
NPI:1255012126
Name:BOLLER, MADISON (PA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BOLLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 PRINCETON PL
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-3047
Mailing Address - Country:US
Mailing Address - Phone:785-317-0485
Mailing Address - Fax:
Practice Address - Street 1:4201 ANDERSON AVE STE C
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-7603
Practice Address - Country:US
Practice Address - Phone:785-539-3504
Practice Address - Fax:785-539-8597
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant