Healthcare Provider Details

I. General information

NPI: 1053236885
Provider Name (Legal Business Name): MR. HASANI K BOLDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720B MEDICAL PARK DR
BILOXI MS
39532-2131
US

IV. Provider business mailing address

220 VIRGINIA AVE
PICAYUNE MS
39466-4658
US

V. Phone/Fax

Practice location:
  • Phone: 228-822-6300
  • Fax:
Mailing address:
  • Phone: 601-916-9790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number197906
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: