Provider Demographics
NPI:1871038265
Name:BOLLING, ELISSA ANN (PA)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:ANN
Last Name:BOLLING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1849
Mailing Address - Country:US
Mailing Address - Phone:336-414-4041
Mailing Address - Fax:
Practice Address - Street 1:13640 STEELECROFT PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7565
Practice Address - Country:US
Practice Address - Phone:704-512-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant