Provider Demographics
NPI:1922070762
Name:BOLDT, MARK D (NP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BOLDT
Suffix:
Gender:M
Credentials:NP
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Mailing Address - Street 1:PO BOX 14909
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0909
Mailing Address - Country:US
Mailing Address - Phone:612-870-5557
Mailing Address - Fax:612-870-5857
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 423 SOUTH
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:612-870-5557
Practice Address - Fax:612-870-5857
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR0901701363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP34925Medicare UPIN