Healthcare Provider Details

I. General information

NPI: 1104840487
Provider Name (Legal Business Name): ALAN D HOLT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N 1ST E
PRESTON ID
83263-1326
US

IV. Provider business mailing address

PO BOX 403
PRESTON ID
83263-0403
US

V. Phone/Fax

Practice location:
  • Phone: 208-852-0137
  • Fax:
Mailing address:
  • Phone: 208-523-4906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-26
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: