Provider Demographics
NPI:1326735002
Name:BOLALIN, DEREK (CRNP)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BOLALIN
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 WASHINGTON RD STE 110A
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5779
Mailing Address - Country:US
Mailing Address - Phone:619-252-1730
Mailing Address - Fax:
Practice Address - Street 1:826 WASHINGTON RD STE 110A
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5779
Practice Address - Country:US
Practice Address - Phone:619-252-1730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR237327363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily