Provider Demographics
NPI:1427033992
Name:BOLEN, LYDIA K (PA-C)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:K
Last Name:BOLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:K
Other - Last Name:CARTWRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 WEALTHY ST SE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2969
Practice Address - Country:US
Practice Address - Phone:616-267-7293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004004363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460296Medicare PIN
MI0N69220Medicare ID - Type Unspecified