Healthcare Provider Details

I. General information

NPI: 1104894047
Provider Name (Legal Business Name): KEN V HOLT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KENNY V HOLT DO

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 WYOMING ST
LANDER WY
82520-3919
US

IV. Provider business mailing address

125 WYOMING ST
LANDER WY
82520-3919
US

V. Phone/Fax

Practice location:
  • Phone: 307-206-1330
  • Fax: 307-206-1331
Mailing address:
  • Phone: 307-206-1330
  • Fax: 307-206-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2005020340
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number13534A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: