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General NPI Number Information
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NPI Number | 1073895017
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Entity Type | Individual
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Provider Name | EDWARD DE JESUS BOLANOS CAA
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Gender | Male
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Dates
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Enumeration Date | 09/15/2011
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Last Update Date | 03/29/2021
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Provider Practice Location Address
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Address Line | 1901 SW 172ND AVE
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City | MIRAMAR
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State | FL
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Zip | 33029-5592
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Country | US
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Telephone | 954-838-2371
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Fax | 954-851-1746
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Provider Business Mailing Address
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Address Line | 7700 W SUNRISE BLVD
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City | PLANTATION
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State | FL
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Zip | 33322-4113
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Country | US
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Telephone | 954-838-2371
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Fax | 954-851-1746
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367H00000X
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Taxonomy Name | Anesthesiologist Assistant
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License Number | AA97
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License Number State | FL
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