Provider Demographics
NPI:1275641342
Name:BOLTON, KRISTEN (PA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 N TARRANT PKWY STE 210
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5416
Mailing Address - Country:US
Mailing Address - Phone:682-593-6660
Mailing Address - Fax:888-289-2380
Practice Address - Street 1:3800 N TARRANT PKWY STE 210
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5416
Practice Address - Country:US
Practice Address - Phone:682-593-6660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX413691YKPWMedicare PIN
TX8G2476Medicare PIN
TXQ59647Medicare UPIN