Provider Demographics
NPI:1902176605
Name:BOLDER-GOOLSBY, TIRA LYNN (NP)
Entity Type:Individual
Prefix:MS
First Name:TIRA
Middle Name:LYNN
Last Name:BOLDER-GOOLSBY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 S. LANCASTER
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TEXAS
Mailing Address - Zip Code:75216
Mailing Address - Country:UM
Mailing Address - Phone:214-857-4316
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-857-4316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP121853363LA2100X
KS53-460003-032363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1902176605Medicare NSC