Provider Demographics
NPI:1326141516
Name:BOLT, JASON D (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:BOLT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 S PACA ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1791
Mailing Address - Country:US
Mailing Address - Phone:410-328-7030
Mailing Address - Fax:410-328-7030
Practice Address - Street 1:11 S PACA ST
Practice Address - Street 2:SUITE 500
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1791
Practice Address - Country:US
Practice Address - Phone:410-328-7030
Practice Address - Fax:410-328-7030
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR173732367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered