Healthcare Provider Details

I. General information

NPI: 1902376023
Provider Name (Legal Business Name): JEFFREY HOLTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2018
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10862 CALLE VERDE # S93
LA MESA CA
91941
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD # 4S-205
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 619-660-1822
  • Fax:
Mailing address:
  • Phone: 858-605-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA56316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: