Provider Demographics
NPI:1003513979
Name:HOLM, KAYLA MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MAE
Last Name:HOLM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:MAE
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15650 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7283
Mailing Address - Country:US
Mailing Address - Phone:952-997-4100
Mailing Address - Fax:
Practice Address - Street 1:15650 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7283
Practice Address - Country:US
Practice Address - Phone:952-997-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1200577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant