Healthcare Provider Details

I. General information

NPI: 1417154428
Provider Name (Legal Business Name): MATTHEW ANDREW BOLSOY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 01/21/2026
Certification Date: 01/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

505 NE 87TH AVE STE 210
VANCOUVER WA
98664-1988
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-2000
  • Fax: 360-414-7638
Mailing address:
  • Phone: 360-828-5396
  • Fax: 360-502-9283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30007719
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: