Provider Demographics
NPI:1316415672
Name:BOLDUC, BRANDON (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BOLDUC
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 1:380 SUMMIT AVENUE
Mailing Address - Street 2:MSO PHYSICIAN BILLING
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-283-7597
Mailing Address - Fax:740-283-7807
Practice Address - Street 1:106 PLAZA DR
Practice Address - Street 2:
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-6700
Practice Address - Country:US
Practice Address - Phone:800-318-1794
Practice Address - Fax:234-285-6816
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2180363A00000X
OH50.006507RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0330256Medicaid