Provider Demographics
NPI:1891163598
Name:BOLTON, MATTHEW DANE (CNP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DANE
Last Name:BOLTON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-544-1261
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:511 W LAUREL AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3504
Practice Address - Country:US
Practice Address - Phone:601-544-1261
Practice Address - Fax:601-583-9993
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR885021363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880352Medicaid