Basic Information
| Provider Information | |||||||||
| NPI: | 1548915820 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLANOS | ||||||||
| FirstName: | HERIBERTO | ||||||||
| MiddleName: | ENRIQUE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 RILEY LN | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786243562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Practice Location | |||||||||
| Address1: | 2950 E OLD SETTLERS BLVD UNIT 30 | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786652478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2022 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 246ZC0007X | 196515 | TX | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.