1376803189 NPI number — MRS. LATOYA TRENISE BOLDS-JOHNSON PA-C

Table of content: MRS. LATOYA TRENISE BOLDS-JOHNSON PA-C (NPI 1376803189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376803189 NPI number — MRS. LATOYA TRENISE BOLDS-JOHNSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLDS-JOHNSON
Provider First Name:
LATOYA
Provider Middle Name:
TRENISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOLDS
Provider Other First Name:
LATOYA
Provider Other Middle Name:
TRENISE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376803189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 EMBARCADERO CTR STE 1900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94111-3723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-658-6791
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 CONNECTICUT AVE NW STE 1250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20036-1728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-627-1901
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  C04725 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9481 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA08440 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: C04725 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA031955 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA08440 . This is a "TEXAS MEDICAL BOARD PA LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: C04725 . This is a "MARYLAND PHYSICIAN ASSISTANT LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".