Provider Demographics
NPI:1053369603
Name:BOLIN, LANCE W (PA-C)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:W
Last Name:BOLIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 EDWARD CURD LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-5791
Mailing Address - Country:US
Mailing Address - Phone:615-791-2630
Mailing Address - Fax:615-791-2639
Practice Address - Street 1:3000 EDWARD CURD LN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-5791
Practice Address - Country:US
Practice Address - Phone:615-791-2630
Practice Address - Fax:615-791-2639
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002078363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0069469Medicaid
OH000000622701OtherANTHEM
OHPA24152Medicare PIN
OH000000622701OtherANTHEM
OH0069469Medicaid
OH0069469Medicaid