Provider Demographics
NPI:1528313681
Name:BOLHA, ANNA L (PA-C)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:L
Last Name:BOLHA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 JOHN Q HAMMONS DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1967
Mailing Address - Country:US
Mailing Address - Phone:608-410-2700
Mailing Address - Fax:608-410-2905
Practice Address - Street 1:1200 JOHN Q HAMMONS DR STE 400
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1967
Practice Address - Country:US
Practice Address - Phone:608-410-2700
Practice Address - Fax:608-410-2905
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2971-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528313681Medicaid