Provider Demographics
NPI:1538189048
Name:BOLEWARE, ANGELA L (FNP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:BOLEWARE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:DEPT OF INTERNAL MEDICINE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5660
Mailing Address - Fax:601-984-6870
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE/DIVISION OF GENERAL INTERNAL MED
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR543195207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09538704Medicaid
MSRR P00321105OtherRAILROAD
MSP01236766OtherRAILROAD MEDICARE PTAN
MS302I507067Medicare PIN
MS500002116Medicare ID - Type Unspecified
MSRR P00321105OtherRAILROAD
MS09538704Medicaid