Basic Information
| Provider Information | |||||||||
| NPI: | 1013466846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLTON | ||||||||
| FirstName: | ALEX | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5717 PACIFIC CENTER BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921214250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588591188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5717 PACIFIC CENTER BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921214250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588591188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 21844 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 95007920 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.