Basic Information
| Provider Information | |||||||||
| NPI: | 1922170943 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLTON | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2950 W DELHI RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481039010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347694809 | ||||||||
| FaxNumber: | 7347694809 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 NORTH EAST AVENUE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884963 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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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 | 367500000X | 4704075734 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 018136 | 01 | CRNA AANA | OTHER |