Healthcare Provider Details

I. General information

NPI: 1417480716
Provider Name (Legal Business Name): ANNA J HOLMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA LEE JACKSON

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 ROUND VALLEY DR STE 110
PARK CITY UT
84060-7552
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 435-658-6750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number10957120-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10957120-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: