Provider Demographics
NPI:1417024670
Name:BOLAND, PAUL A (CPO)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:A
Last Name:BOLAND
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 LUCKY DEBONAIR DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1212
Mailing Address - Country:US
Mailing Address - Phone:478-953-2922
Mailing Address - Fax:478-953-2927
Practice Address - Street 1:110 OSIGIAN BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7880
Practice Address - Country:US
Practice Address - Phone:478-953-2922
Practice Address - Fax:478-953-2927
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000006174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000006OtherSTATE O&P LICENSE
GACPO 1780OtherABC CERT PROSTH & ORTHO