Provider Demographics
NPI:1104877018
Name:BOLTE, STEFANIE L
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:L
Last Name:BOLTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8577
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68108-0577
Mailing Address - Country:US
Mailing Address - Phone:402-397-7989
Mailing Address - Fax:402-397-8703
Practice Address - Street 1:10707 PACIFIC ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4762
Practice Address - Country:US
Practice Address - Phone:402-397-7989
Practice Address - Fax:402-393-7554
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44887208800000X
NE23778208800000X
IA36776208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098396OtherMEDICARE
NEI66053Medicare UPIN
IA70090Medicare PIN