Provider Demographics
NPI:1073651337
Name:BOLANGER, KRISTA D (PA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:D
Last Name:BOLANGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 N MAIN ST
Mailing Address - Street 2:SUITE 227
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:937-832-4773
Mailing Address - Fax:937-832-2986
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:SUITE 227
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-832-4773
Practice Address - Fax:937-832-2986
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50 002179363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067813Medicaid
OHPA23412Medicare PIN