Provider Demographics
NPI:1376170514
Name:BOLTON, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BOLTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:OLIVER SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37840-5008
Mailing Address - Country:US
Mailing Address - Phone:865-435-1933
Mailing Address - Fax:
Practice Address - Street 1:103 BENNETT RD
Practice Address - Street 2:
Practice Address - City:OLIVER SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37840-5008
Practice Address - Country:US
Practice Address - Phone:865-435-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN64355207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ058332Medicaid