Basic Information
| Provider Information | |||||||||
| NPI: | 1801801568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLSER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DECLUE | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | CAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 611 W PARK ST | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 311 W FAIRCHILD ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618323876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174317898 | ||||||||
| FaxNumber: | 2175541750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209-000358 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | CE9335 | 01 | IL | RR GROUP | OTHER | P00393307 | 01 | IL | RR MEDICARE NUMBER | OTHER |