Jacob Thomas Bolz, PA-C
Individual provider Active NPI Physician Assistant · Lakeside, CA
NPI 1386025682 · NPPES record last updated Jun 11, 2015
Key facts
- NPI
- 1386025682
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- 52510 (CA)
- Practice address
- 12517 Lakeshore Dr
Lakeside, CA 92040-3103 - Phone
- (619) 443-3843
- NPI assigned
- Jun 11, 2015
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150709002441 | CA | Order and Referring Only - Physician Assistant | 8426360058 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 52510 | CA | MD | Pharmacist |
Interoperability endpoints
- jbolz17606@sharphealthcare.direct-ci.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 52510 | CA | Yes |
Addresses
Primary practice location
12517 Lakeshore Dr
Lakeside, CA 92040-3103
Mailing address
12517 Lakeshore Dr
Lakeside, CA 92040-3103
Phone (619) 443-3843
Other providers in Lakeside, CA
- Tracie Lynne Bjorkman
- Burch Lee Blackstock
- Blackstockdentalcorp
- Bliss & Zen Acupuncture Health and Wellness LLC
- Yarisel Blumka
- Bright Balance Inc
- Keri Bruner
- Rebecca Anne Bumi
- Tricia Rose Callicoat
- Caredriven Transportation LLC
All providers in Lakeside, CA · Physician Assistant in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 11, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.