Provider Demographics
NPI:1407193840
Name:BOLANOS, ISSAC ISAIAH (PA)
Entity Type:Individual
Prefix:
First Name:ISSAC
Middle Name:ISAIAH
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 RED RIVER ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1943
Mailing Address - Country:US
Mailing Address - Phone:512-391-1751
Mailing Address - Fax:512-391-1906
Practice Address - Street 1:1313 RED RIVER ST
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1943
Practice Address - Country:US
Practice Address - Phone:512-391-1751
Practice Address - Fax:512-391-1906
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08063363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA08063OtherTX LICENSE