Healthcare Provider Details

I. General information

NPI: 1316415672
Provider Name (Legal Business Name): BRANDON BOLDUC PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 COLLIERS WAY STE 511
WEIRTON WV
26062-5054
US

IV. Provider business mailing address

651 COLLIERS WAY STE 511
WEIRTON WV
26062-5054
US

V. Phone/Fax

Practice location:
  • Phone: 304-723-6801
  • Fax:
Mailing address:
  • Phone: 304-723-6801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2180
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006507RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: