Provider Demographics
NPI:1083190649
Name:BOLES, WYATT JAMES (DO)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:JAMES
Last Name:BOLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7321 BALMER AVE
Mailing Address - Street 2:BLDG 570
Mailing Address - City:HILL AFB
Mailing Address - State:UT
Mailing Address - Zip Code:84332
Mailing Address - Country:US
Mailing Address - Phone:801-707-4787
Mailing Address - Fax:
Practice Address - Street 1:7321 BALMER AVE
Practice Address - Street 2:BLDG 570
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84332
Practice Address - Country:US
Practice Address - Phone:801-707-4787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7685502-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine