Provider Demographics
NPI:1083243927
Name:BOULDING, THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BOULDING
Suffix:
Gender:M
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 1:521 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-3506
Mailing Address - Country:US
Mailing Address - Phone:305-978-4342
Mailing Address - Fax:
Practice Address - Street 1:123 2ND AVE S STE 105
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-8457
Practice Address - Country:US
Practice Address - Phone:425-678-6139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty