Provider Demographics
NPI:1972118776
Name:BOLLICH, EMMA W (PA-C)
Entity type:Individual
Prefix:MRS
First Name:EMMA
Middle Name:W
Last Name:BOLLICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:123 COUNTRY LIVING DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-2108
Mailing Address - Country:US
Mailing Address - Phone:337-501-5279
Mailing Address - Fax:
Practice Address - Street 1:6703 AMBASSADOR CAFFERY PKWY STE 2
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-5283
Practice Address - Country:US
Practice Address - Phone:337-948-1766
Practice Address - Fax:337-948-1768
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA324303363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical