MEDICARE: MATTHEW HOLT ATC, PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL 3973	FL
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1477955524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW HOLT ATC, PA-C

Provider Business Mailing Address
First Line	:	10815 COLONEL GLENN RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72204-8011
Country	:	US
Telephone Number	:	501-406-9203
Fax Number	:	501-320-7813

Provider Business Practice Location Address
First Line	:	10815 COLONEL GLENN RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72204-8011
Country	:	US
Telephone Number	:	501-406-9203
Fax Number	:	501-320-7813

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2014
Last Update Date	:	03/24/2020

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