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General NPI Number Information
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NPI Number | 1548147390
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Entity Type | Individual
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Provider Name | BRANDON ELLIS BOLTON PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/21/2025
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Last Update Date | 08/21/2025
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Provider Practice Location Address
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Address Line | MEDICAL CENTER BLVD
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City | WINSTON SALEM
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State | NC
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Zip | 27157-0001
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Country | US
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Telephone | 336-716-2011
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Fax |
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Provider Business Mailing Address
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Address Line | 2309 AUTUMN MIST DR
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City | WINSTON SALEM
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State | NC
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Zip | 27103-7061
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Country | US
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Telephone | 760-391-2101
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Fax |
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 001015658
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License Number State | NC
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