Provider Demographics
NPI:1053170449
Name:BAO, BO (MD)
Entity type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:BAO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11131 85 AVE NW
Mailing Address - Street 2:UNIT 101
Mailing Address - City:EDMONTON
Mailing Address - State:ALBERTA
Mailing Address - Zip Code:T6G0W7
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:587-785-8651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2025-02-21
Deactivation Date:2024-10-23
Deactivation Code:
Reactivation Date:2025-02-21
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program