Provider Demographics
NPI:1376803189
Name:BOLDS-JOHNSON, LATOYA TRENISE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LATOYA
Middle Name:TRENISE
Last Name:BOLDS-JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LATOYA
Other - Middle Name:TRENISE
Other - Last Name:BOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 EMBARCADERO CTR STE 1900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3723
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:1350 CONNECTICUT AVE NW STE 1250
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-1728
Practice Address - Country:US
Practice Address - Phone:202-627-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-26
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04725363A00000X, 363AM0700X
MAPA9481363A00000X
TXPA08440363AM0700X
DCPA031955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA08440OtherTEXAS MEDICAL BOARD PA LICENSE
MDC04725OtherMARYLAND PHYSICIAN ASSISTANT LICENSE