Provider Demographics
NPI:1770067266
Name:BOLYARD, THERESA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:BOLYARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7337 CARITAS CIR NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-9126
Mailing Address - Country:US
Mailing Address - Phone:330-830-6110
Mailing Address - Fax:
Practice Address - Street 1:7337 CARITAS CIR NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-9126
Practice Address - Country:US
Practice Address - Phone:330-830-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005712RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant