Provider Demographics
NPI:1043607054
Name:BOLDUC, KATIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 CHAPLINE ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3875
Mailing Address - Country:US
Mailing Address - Phone:304-233-3240
Mailing Address - Fax:304-232-6128
Practice Address - Street 1:2101 CHAPLINE ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3875
Practice Address - Country:US
Practice Address - Phone:304-233-3240
Practice Address - Fax:304-232-6128
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV01855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant