Provider Demographics
NPI:1609946839
Name:BOLAN, DENISE M (RPA C)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:BOLAN
Suffix:
Gender:F
Credentials:RPA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SANTANONI DR
Mailing Address - Street 2:
Mailing Address - City:NEWCOMB
Mailing Address - State:NY
Mailing Address - Zip Code:12852-1913
Mailing Address - Country:US
Mailing Address - Phone:518-582-2991
Mailing Address - Fax:518-582-2393
Practice Address - Street 1:4 SANTANONI DR
Practice Address - Street 2:
Practice Address - City:NEWCOMB
Practice Address - State:NY
Practice Address - Zip Code:12852
Practice Address - Country:US
Practice Address - Phone:518-582-2991
Practice Address - Fax:518-582-2040
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0027151207Q00000X
NY002715363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01110874Medicaid
NYBB9575Medicare PIN
NY01110874Medicaid