Provider Demographics
NPI:1396532511
Name:BOLANOS LOPEZ, JOAN SEBASTIAN (PA-C)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:SEBASTIAN
Last Name:BOLANOS LOPEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:
Practice Address - Street 1:5160 OCEAN HWY W
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4012
Practice Address - Country:US
Practice Address - Phone:910-617-8325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-15626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant