Healthcare Provider Details

I. General information

NPI: 1376722009
Provider Name (Legal Business Name): SHEA RYAN HOLT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 8TH AVE
FORT WORTH TX
76110-1812
US

IV. Provider business mailing address

2221 8TH AVE
FORT WORTH TX
76110-1812
US

V. Phone/Fax

Practice location:
  • Phone: 817-336-5060
  • Fax: 817-336-1744
Mailing address:
  • Phone: 817-336-5060
  • Fax: 817-336-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberN9377
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: