Healthcare Provider Details

I. General information

NPI: 1467733816
Provider Name (Legal Business Name): ANDREA M BOLESTA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ARRANDALE BLVD
EXTON PA
19341-2503
US

IV. Provider business mailing address

1296 GROVE RD
WEST CHESTER PA
19380-1062
US

V. Phone/Fax

Practice location:
  • Phone: 610-363-2532
  • Fax:
Mailing address:
  • Phone: 610-585-0192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00265400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA055091
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: