Provider Demographics
NPI:1932613809
Name:BOLDING, BRENN ALINE (PA-C, MS, LAT)
Entity type:Individual
Prefix:
First Name:BRENN
Middle Name:ALINE
Last Name:BOLDING
Suffix:
Gender:F
Credentials:PA-C, MS, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:3001 EDWARDS MILL RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5243
Mailing Address - Country:US
Mailing Address - Phone:919-781-5600
Mailing Address - Fax:
Practice Address - Street 1:3001 EDWARDS MILL RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5243
Practice Address - Country:US
Practice Address - Phone:919-863-6856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NC0010-14785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer