Healthcare Provider Details

I. General information

NPI: 1467478396
Provider Name (Legal Business Name): RICHARD L HOLMES JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 MESQUITE AVE STE B
LAKE HAVASU CITY AZ
86403-5886
US

IV. Provider business mailing address

11010 N DESERT VIEW LN
FLAGSTAFF AZ
86004-1787
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-4600
  • Fax:
Mailing address:
  • Phone: 928-600-7630
  • Fax: 928-600-7630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7129
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number7129
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: