Provider Demographics
NPI:1518785146
Name:BOLSER, CRYSTAL MARIE (AGNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:BOLSER
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:WALCOTT
Mailing Address - State:IA
Mailing Address - Zip Code:52773-0623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 30TH AVE STE 12
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5975
Practice Address - Country:US
Practice Address - Phone:309-736-5568
Practice Address - Fax:309-736-1152
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH181589363L00000X
IL209031246207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner