Provider Demographics
NPI:1053865436
Name:BOLBOTOWSKI, AMANDA T (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:T
Last Name:BOLBOTOWSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 HARVARD AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3504
Mailing Address - Country:US
Mailing Address - Phone:203-243-7505
Mailing Address - Fax:
Practice Address - Street 1:376 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2892
Practice Address - Country:US
Practice Address - Phone:617-923-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA5788OtherPA LICENSE