Provider Demographics
NPI:1275641342
Name:BOLTON, KRISTEN (PA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BOLTON
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 1:6100 LAKE WORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3703
Mailing Address - Country:US
Mailing Address - Phone:817-237-3321
Mailing Address - Fax:817-237-7970
Practice Address - Street 1:6100 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3703
Practice Address - Country:US
Practice Address - Phone:817-237-3321
Practice Address - Fax:817-237-7970
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX413691YKPWMedicare PIN
TX8G2476Medicare PIN
TXQ59647Medicare UPIN