Healthcare Provider Details

I. General information

NPI: 1376803189
Provider Name (Legal Business Name): LATOYA TRENISE BOLDS-JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LATOYA TRENISE BOLDS PA-C

II. Dates (important events)

Enumeration Date: 05/26/2012
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 CONNECTICUT AVE NW STE 1250
WASHINGTON DC
20036-1728
US

IV. Provider business mailing address

1 EMBARCADERO CTR STE 1900
SAN FRANCISCO CA
94111-3723
US

V. Phone/Fax

Practice location:
  • Phone: 202-627-1901
  • Fax:
Mailing address:
  • Phone: 415-658-6791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC04725
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9481
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA08440
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC04725
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031955
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: