Provider Demographics
NPI:1629345608
Name:BOLTUC, KYOUNG S
Entity Type:Individual
Prefix:MRS
First Name:KYOUNG
Middle Name:S
Last Name:BOLTUC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629TH MEDICAL COMPANY
Mailing Address - Street 2:UNIT # 15342
Mailing Address - City:APO AP
Mailing Address - State:CA
Mailing Address - Zip Code:96258-5342
Mailing Address - Country:US
Mailing Address - Phone:315-732-7396
Mailing Address - Fax:
Practice Address - Street 1:629TH MEDICAL COMPANY
Practice Address - Street 2:UNIT # 15342
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96258-5342
Practice Address - Country:US
Practice Address - Phone:315-732-7396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403434163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0106XNursing Service ProvidersRegistered NurseOccupational Health