Healthcare Provider Details

I. General information

NPI: 1093483638
Provider Name (Legal Business Name): RUSSELL HOLDER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S 32ND ST
MUSKOGEE OK
74401-5012
US

IV. Provider business mailing address

615 S 32ND ST
MUSKOGEE OK
74401-5012
US

V. Phone/Fax

Practice location:
  • Phone: 539-239-5240
  • Fax: 539-239-5249
Mailing address:
  • Phone: 539-239-5240
  • Fax: 539-239-5249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4945
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: