Provider Demographics
NPI:1598199291
Name:BOLIVAR, STEPHEN (NP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:BOLIVAR
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 S 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4227
Mailing Address - Country:US
Mailing Address - Phone:601-651-2832
Mailing Address - Fax:601-651-2835
Practice Address - Street 1:235 S 14TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4227
Practice Address - Country:US
Practice Address - Phone:601-651-2832
Practice Address - Fax:601-651-2835
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR888641363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07029064Medicaid
MS07029064Medicaid