1982942587 NPI number — JENNIFER BOLIN GOULD CRNA

Table of content: JENNIFER BOLIN GOULD CRNA (NPI 1982942587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982942587 NPI number — JENNIFER BOLIN GOULD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOULD
Provider First Name:
JENNIFER
Provider Middle Name:
BOLIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982942587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 GOLF ACRES DR
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28208-5906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-512-6428
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10628 PARK RD
Provider Second Line Business Practice Location Address:
ANESTHESIA SERVICES
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-8407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-667-1970
Provider Business Practice Location Address Fax Number:
704-667-1684
Provider Enumeration Date:
01/17/2013

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: 367500000X , with the licence number:  238403 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8054354 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: NAN153 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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