Provider Demographics
NPI:1902176605
Name:BOLDER, TIRA LYNN (NP)
Entity type:Individual
Prefix:MS
First Name:TIRA
Middle Name:LYNN
Last Name:BOLDER
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E FM 1382 UNIT 4321
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75106-5198
Mailing Address - Country:US
Mailing Address - Phone:945-240-1598
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-857-4316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-460003-032363LA2100X
TXAP121853363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1902176605Medicare NSC