Provider Demographics
NPI:1336535657
Name:BOLDUAN, ALYSSA JOY
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JOY
Last Name:BOLDUAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 RANDALL RD STE 202
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4204
Mailing Address - Country:US
Mailing Address - Phone:630-938-3900
Mailing Address - Fax:
Practice Address - Street 1:302 RANDALL RD STE 202
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4204
Practice Address - Country:US
Practice Address - Phone:630-938-3900
Practice Address - Fax:630-938-3910
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN60967207Y00000X
IL036156561207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program