Healthcare Provider Details

I. General information

NPI: 1528277134
Provider Name (Legal Business Name): WAYNE EDWARD BOULTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 N TENAYA WAY
LAS VEGAS NV
89128-0424
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-8600
  • Fax: 702-242-7944
Mailing address:
  • Phone: 702-383-6210
  • Fax: 702-435-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number730
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 1456
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: