Healthcare Provider Details

I. General information

NPI: 1508932450
Provider Name (Legal Business Name): MICKEL A HOLMAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 DAVENPORT
MER ROUGE LA
71261
US

IV. Provider business mailing address

PO BOX 4522
MONROE LA
71211-4522
US

V. Phone/Fax

Practice location:
  • Phone: 318-647-3412
  • Fax:
Mailing address:
  • Phone: 318-518-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200114
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: