Provider Demographics
NPI:1831672260
Name:BOLDERSON, AUNGELIQUE JOAN (PA-C)
Entity Type:Individual
Prefix:
First Name:AUNGELIQUE
Middle Name:JOAN
Last Name:BOLDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8251 W BROWARD BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2703
Mailing Address - Country:US
Mailing Address - Phone:954-475-9244
Mailing Address - Fax:954-475-0848
Practice Address - Street 1:8251 W BROWARD BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2703
Practice Address - Country:US
Practice Address - Phone:954-475-9244
Practice Address - Fax:954-475-0848
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
FLPA9111588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant