Healthcare Provider Details

I. General information

NPI: 1740458835
Provider Name (Legal Business Name): NICHOLAS NEAL HOLMES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5803 NEAL AVE N
OAK PARK HEIGHTS MN
55082-2177
US

IV. Provider business mailing address

5803 NEAL AVE N
OAK PARK HEIGHTS MN
55082-2177
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-8807
  • Fax: 651-439-0232
Mailing address:
  • Phone: 651-439-8807
  • Fax: 651-439-0232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number106245
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31006
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301090597
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: