Provider Demographics
NPI:1831790591
Name:BOLTZ, BAILEY N (PA-C)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:N
Last Name:BOLTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:N
Other - Last Name:MANTHA-NAGRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3801 5TH ST SE STE 110
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2106
Mailing Address - Country:US
Mailing Address - Phone:253-845-9585
Mailing Address - Fax:253-848-1126
Practice Address - Street 1:3801 5TH ST SE STE 110
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2106
Practice Address - Country:US
Practice Address - Phone:253-845-9585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-07
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61101539363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2171601Medicaid