Provider Demographics
NPI:1528362159
Name:BOLSTAD, CARLYE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLYE
Middle Name:
Last Name:BOLSTAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 HARRISON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-6897
Mailing Address - Country:US
Mailing Address - Phone:406-565-5730
Mailing Address - Fax:406-565-5734
Practice Address - Street 1:3703 HARRISON AVE STE B
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-6897
Practice Address - Country:US
Practice Address - Phone:406-565-5730
Practice Address - Fax:405-565-5734
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA159424363AM0700X
MTMED-PAC-LIC-68538363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical