Healthcare Provider Details

I. General information

NPI: 1265468425
Provider Name (Legal Business Name): CAROL ANN BOLT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6060 PORTAL WAY
FERNDALE WA
98248-7833
US

IV. Provider business mailing address

6060 PORTAL WAY
FERNDALE WA
98248-7833
US

V. Phone/Fax

Practice location:
  • Phone: 360-676-6177
  • Fax: 360-671-3574
Mailing address:
  • Phone: 360-676-6177
  • Fax: 360-671-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0004322
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000102439
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number61678220
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: