Basic Information
| Provider Information | |||||||||
| NPI: | 1104877018 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLTE | ||||||||
| FirstName: | STEFANIE | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8577 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681080577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977989 | ||||||||
| FaxNumber: | 4023978703 | ||||||||
| Practice Location | |||||||||
| Address1: | 10707 PACIFIC ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681144762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977989 | ||||||||
| FaxNumber: | 4023937554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 44887 | WI | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 23778 | NE | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | 36776 | IA | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 098396 | 01 | NE | MEDICARE | OTHER |