Healthcare Provider Details

I. General information

NPI: 1588663165
Provider Name (Legal Business Name): THOMAS WILLIAM HOLTGRAVE A.P.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 N BUS US HWY 65 STE. 504
BRANSON MO
65616-4500
US

IV. Provider business mailing address

545 N BUS US HWY 65 STE. 504
BRANSON MO
65616-4500
US

V. Phone/Fax

Practice location:
  • Phone: 417-335-2080
  • Fax: 417-336-3583
Mailing address:
  • Phone: 417-335-2080
  • Fax: 417-336-3583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number066289
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: