Provider Demographics
NPI:1801845292
Name:BOLTON, NGOZI IHEANACHO (PAA)
Entity Type:Individual
Prefix:
First Name:NGOZI
Middle Name:IHEANACHO
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 JOHNSON FY RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1605
Mailing Address - Country:US
Mailing Address - Phone:404-785-2008
Mailing Address - Fax:404-785-4496
Practice Address - Street 1:1001 JOHNSON FY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1605
Practice Address - Country:US
Practice Address - Phone:404-785-2008
Practice Address - Fax:404-785-4496
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2442367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant