Provider Demographics
NPI:1487053823
Name:WOLTER, BRIAN JOSEPH
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:WOLTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38725 BEARS PAW DR
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-3011
Mailing Address - Country:US
Mailing Address - Phone:951-219-5105
Mailing Address - Fax:
Practice Address - Street 1:38725 BEARS PAW DR
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-3011
Practice Address - Country:US
Practice Address - Phone:951-219-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-1145363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant