Provider Demographics
NPI:1801400353
Name:BOLES, ALYSSA HORTON (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:HORTON
Last Name:BOLES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:HORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:723 S VAN BUREN RD STE B
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5321
Mailing Address - Country:US
Mailing Address - Phone:336-623-5171
Mailing Address - Fax:336-627-5747
Practice Address - Street 1:723 S VAN BUREN RD STE B
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5321
Practice Address - Country:US
Practice Address - Phone:336-623-5171
Practice Address - Fax:336-627-5747
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-10625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant