Healthcare Provider Details

I. General information

NPI: 1922070762
Provider Name (Legal Business Name): MARK D BOLDT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W SUITE 423 SOUTH
SAINT PAUL MN
55114-1052
US

IV. Provider business mailing address

PO BOX 14909
MINNEAPOLIS MN
55414-0909
US

V. Phone/Fax

Practice location:
  • Phone: 612-870-5557
  • Fax: 612-870-5857
Mailing address:
  • Phone: 612-870-5557
  • Fax: 612-870-5857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR0901701
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: