Provider Demographics
NPI:1538461686
Name:BOLDEN, ALICIA RENA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:RENA
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:RENA
Other - Last Name:MCWHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:407 SE 24TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-3915
Mailing Address - Country:US
Mailing Address - Phone:954-467-2140
Mailing Address - Fax:
Practice Address - Street 1:407 SE 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-3915
Practice Address - Country:US
Practice Address - Phone:954-467-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103331363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical