Provider Demographics
NPI:1982684965
Name:BOYLE, BRADLEY D (PA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:BOYLE
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 1:6771 N 200 E
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:955 HIGH ST
Practice Address - Street 2:STE 2
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2326
Practice Address - Country:US
Practice Address - Phone:260-724-8700
Practice Address - Fax:260-728-3821
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000289A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P77871Medicare UPIN
148540CMedicare ID - Type Unspecified