Provider Demographics
NPI:1356886584
Name:BOLT, MEREDITH STORM (PA)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:STORM
Last Name:BOLT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:
Other - Last Name:STORM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2701 N ROCKWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-5246
Mailing Address - Country:US
Mailing Address - Phone:405-789-4150
Mailing Address - Fax:
Practice Address - Street 1:2701 N ROCKWELL AVE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5246
Practice Address - Country:US
Practice Address - Phone:405-789-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-26
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant