Provider Demographics
NPI:1912983305
Name:BOLES, GINGER (PA)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:BOLES
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 1:1 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301
Mailing Address - Country:US
Mailing Address - Phone:304-623-3461
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:CLARKBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001718071OtherWV BCBS
WV1066361OtherWV DWC
WVS97556Medicare UPIN
WV14864Medicare PIN
WV1066361OtherWV DWC
WV14863Medicare PIN
WVP00001439Medicare PIN
WVP00001420Medicare PIN
WV14862Medicare PIN