Provider Demographics
NPI:1396737706
Name:BOLL, VICKIE (PA-C)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:BOLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 GAGE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-8650
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:4804 W CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2119
Practice Address - Country:US
Practice Address - Phone:509-942-2355
Practice Address - Fax:509-222-1289
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA338363A00000X
NVPA1392363A00000X
WAPA60168389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010152179OtherBLUE SHIELD-DOWNEY
ID000010161109OtherBLUE SHIELD MCCAMMON
NV1396737706Medicaid
IDPAND8OtherBLUE CROSS-AM FALLS
IDPANE5OtherBLUE CROSS-DOWNEY
ID000010152180OtherBLUE SHIELD-LAVA
WA2054118Medicaid
ID000010152181OtherBLUE SHIELD-POCATELLO
ID000010152182OtherBLUE SHIELD-AM FALLS
IDPANH9OtherBLUE CROSS-POCATELLO
NVHB721ZOtherMEDICARE PTAN
IDPAE62OtherBLUE CROSS-MCCAMMON
ID807226500Medicaid
IDPANF3OtherBLUE CROSS-ABERDEEN
IDPANG1OtherBLUE CROSS-LAVA
IDPANE5OtherBLUE CROSS-DOWNEY
ID000010152181OtherBLUE SHIELD-POCATELLO
ID807226500Medicaid
ID1665234Medicare PIN
IDPAE62OtherBLUE CROSS-MCCAMMON
IDPANH9OtherBLUE CROSS-POCATELLO
IDP00164679Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID NUMB