Provider Demographics
NPI:1750373981
Name:BOLLIER, ANDREW S (PA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:S
Last Name:BOLLIER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5822
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-484-9603
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5822
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-484-9603
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000595A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN970029681OtherRAIL ROAD MEDCARE
IN970029681Medicare PIN
IN058940DDDMedicare PIN
IN970029681OtherRAIL ROAD MEDCARE
IN058940DDDMedicare ID - Type Unspecified