Healthcare Provider Details

I. General information

NPI: 1255332375
Provider Name (Legal Business Name): ROBERT HOLSTEAD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 BELMONT AVE
LA JUNTA CO
81050-2101
US

IV. Provider business mailing address

128 MARKET ST
ALAMOSA CO
81101-2290
US

V. Phone/Fax

Practice location:
  • Phone: 719-383-5900
  • Fax: 719-383-6533
Mailing address:
  • Phone: 719-589-5161
  • Fax: 719-589-5722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008063
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3650
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: