Provider Demographics
NPI:1881033942
Name:BOLTON, THOMAS TRIMBLE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:TRIMBLE
Last Name:BOLTON
Suffix:
Gender:M
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 1:118 SHENANDOAH DR STE A
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77381-1203
Mailing Address - Country:US
Mailing Address - Phone:281-583-4000
Mailing Address - Fax:
Practice Address - Street 1:118 SHENANDOAH DR STE A
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77381-1203
Practice Address - Country:US
Practice Address - Phone:281-583-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200628363AS0400X
TXPA650816363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX301744YJ97Medicare PIN