Provider Demographics
NPI:1982942587
Name:GOULD, JENNIFER BOLIN (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BOLIN
Last Name:GOULD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 GOLF ACRES DR
Mailing Address - Street 2:STE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5906
Mailing Address - Country:US
Mailing Address - Phone:704-512-6428
Mailing Address - Fax:
Practice Address - Street 1:10628 PARK RD
Practice Address - Street 2:ANESTHESIA SERVICES
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8407
Practice Address - Country:US
Practice Address - Phone:704-667-1970
Practice Address - Fax:704-667-1684
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8054354Medicaid
SCNAN153Medicaid
NC8054354Medicaid