Individual
JEROME DORIAN BOLTZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
MEDICAL CENTER BLVD, WINSTON SALEM, NC 27157-0001
(336) 716-2011
(336) 716-7359
Mailing address
PO BOX 602658, CHARLOTTE, NC 28260-2658
(336) 716-2255
(336) 716-7359
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
5005247
NC
363LF0000X
Family Nurse Practitioner
5005247
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1955 A
MEDICARE PROVIDER #
NC
Enumeration date
05/27/2006
Last updated
01/05/2022
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