Provider Demographics
NPI:1730574211
Name:BOLAND, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:BOLAND
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:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:SAMSON
Mailing Address - State:AL
Mailing Address - Zip Code:36477-0303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2617 PLANTATION COVE CIR
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35226-2861
Practice Address - Country:US
Practice Address - Phone:850-865-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS10383390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program