Provider Demographics
NPI:1285643288
Name:BOLENA, CYNTHIA D (CRNA)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:D
Last Name:BOLENA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-8436
Mailing Address - Country:US
Mailing Address - Phone:480-892-8400
Mailing Address - Fax:480-892-9533
Practice Address - Street 1:1600 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1108
Practice Address - Country:US
Practice Address - Phone:928-776-7477
Practice Address - Fax:928-776-0693
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ045589367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ836489Medicaid
AZ77236Medicare ID - Type Unspecified
AZR85451Medicare UPIN