Provider Demographics
NPI:1891402103
Name:BOLT, WILLIAM SPENCER (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SPENCER
Last Name:BOLT
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 1:1390 5TH ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2631
Mailing Address - Country:US
Mailing Address - Phone:931-253-1110
Mailing Address - Fax:
Practice Address - Street 1:1390 5TH ST
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2631
Practice Address - Country:US
Practice Address - Phone:931-253-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant