Provider Demographics
NPI:1881606713
Name:BOLT, LAURIE A (NP)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:BOLT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2664
Mailing Address - Fax:510-879-9099
Practice Address - Street 1:450 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3513
Practice Address - Country:US
Practice Address - Phone:559-582-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP12024363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04990ZMedicare PIN
CAZZZ04989ZMedicare PIN