Provider Demographics
NPI:1437905601
Name:BOLL, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BOLL
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 1:6807 94TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LAMOURE
Mailing Address - State:ND
Mailing Address - Zip Code:58415-8952
Mailing Address - Country:US
Mailing Address - Phone:701-830-9739
Mailing Address - Fax:
Practice Address - Street 1:1919 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2416
Practice Address - Country:US
Practice Address - Phone:701-234-6076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-27
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL21050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine