Healthcare Provider Details

I. General information

NPI: 1255467379
Provider Name (Legal Business Name): ELIZABETH LAZIER HOLTBY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WILLIAMS WAY
MOAB UT
84532-2185
US

IV. Provider business mailing address

450 WILLIAMS WAY
MOAB UT
84532-2185
US

V. Phone/Fax

Practice location:
  • Phone: 435-719-3500
  • Fax:
Mailing address:
  • Phone: 435-719-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number323
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8576577-1206
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier027031
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerKAISER COMMERCIAL NUMBER
# 2
Identifier07003239
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 3
Identifier1255467379
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: