Provider Demographics
NPI:1952808255
Name:BOLES, NATHAN EDWARD
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:EDWARD
Last Name:BOLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 PETER BRYCE BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-7457
Mailing Address - Country:US
Mailing Address - Phone:205-348-1770
Mailing Address - Fax:205-348-1772
Practice Address - Street 1:1150 N 18TH ST STE 300
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2931
Practice Address - Country:US
Practice Address - Phone:325-670-2255
Practice Address - Fax:833-680-9963
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT1017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program