Provider Demographics
NPI:1063700078
Name:BOLTON, RYAN ELAINE (PA-C)
Entity type:Individual
Prefix:MS
First Name:RYAN
Middle Name:ELAINE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:BOLTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:75 EASTERN POINT RD
Mailing Address - Street 2:STATION A78
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4905
Mailing Address - Country:US
Mailing Address - Phone:860-433-5193
Mailing Address - Fax:
Practice Address - Street 1:75 EASTERN POINT RD
Practice Address - Street 2:STATION A78
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4905
Practice Address - Country:US
Practice Address - Phone:860-433-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2528363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical