Provider Demographics
NPI:1164684692
Name:BOLTON, LARRY EDWARD JR (PA-C)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:EDWARD
Last Name:BOLTON
Suffix:JR
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 1:3000 S IH 35
Mailing Address - Street 2:STE 205
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6513
Mailing Address - Country:US
Mailing Address - Phone:512-912-8200
Mailing Address - Fax:512-912-8206
Practice Address - Street 1:3000 S IH 35
Practice Address - Street 2:STE 205
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6513
Practice Address - Country:US
Practice Address - Phone:512-912-8200
Practice Address - Fax:512-912-8206
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 02475363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical