Provider Demographics
NPI:1568449205
Name:BOLLER, ALEX R (PA-C)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:R
Last Name:BOLLER
Suffix:
Gender:M
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 1:301 HIWASSEE COMMUNITY DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354
Mailing Address - Country:US
Mailing Address - Phone:423-436-7730
Mailing Address - Fax:423-436-0384
Practice Address - Street 1:301 HIWASSEE COMMUNITY DR.
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354
Practice Address - Country:US
Practice Address - Phone:423-436-7730
Practice Address - Fax:423-436-0384
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA-001385-L363A00000X
TN4902207Q00000X
NY004090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
910248OtherNCCPA #
NY004090OtherLICENSE
PAMA-001385-LOtherLICENSE
PAMA-001385-LOtherLICENSE
S49390Medicare UPIN
MB0884331OtherDEA #