Individual
LAURA BOLT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
4805 NE GLISAN ST, STE 6N50, PORTLAND, OR 97213-2933
(503) 215-2300
(503) 215-8004
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
(503) 215-2300
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA174307
OR
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500693080
—
OR
Enumeration date
04/29/2014
Last updated
10/06/2020
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