Healthcare Provider Details

I. General information

NPI: 1801054879
Provider Name (Legal Business Name): JENNIFER A HOLT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 GEIST RD
FAIRBANKS AK
99709-3554
US

IV. Provider business mailing address

3745 GEIST RD
FAIRBANKS AK
99709-3554
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-3338
  • Fax:
Mailing address:
  • Phone: 907-456-3338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number150000
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: