Provider Demographics
NPI:1447290911
Name:BOYLE, ANISSA (PA)
Entity type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:BOYLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SAINT PAUL ST
Mailing Address - Street 2:MERCY MEDICAL CENTER
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:410-332-9036
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL ST
Practice Address - Street 2:MERCY MEDICAL CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052100363A00000X
MDC0003683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q43605Medicare UPIN