Healthcare Provider Details

I. General information

NPI: 1346683547
Provider Name (Legal Business Name): MARY GABRIELLE BOLTON M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9730 3RD AVE NE STE 208
SEATTLE WA
98115-2023
US

IV. Provider business mailing address

25707 SE 30TH ST
SAMMAMISH WA
98075-9176
US

V. Phone/Fax

Practice location:
  • Phone: 206-522-5646
  • Fax: 888-972-4693
Mailing address:
  • Phone: 206-718-3868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00045876
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD00045876
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: