Provider Demographics
NPI:1003810540
Name:HOLSTEN, RAYMOND LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:LEE
Last Name:HOLSTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1625
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-8123
Mailing Address - Fax:928-645-3862
Practice Address - Street 1:467 VISTA AVENUE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-1625
Practice Address - Country:US
Practice Address - Phone:928-645-8123
Practice Address - Fax:928-645-3862
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ145989Medicaid
AZF65558Medicare UPIN
AZ145989Medicaid
AZZ137967Medicare PIN