Provider Demographics
NPI:1083661813
Name:HOLMEN, KENNETH DALE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DALE
Last Name:HOLMEN
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 1:1406 SIXTH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1900
Mailing Address - Country:US
Mailing Address - Phone:320-240-2157
Mailing Address - Fax:320-656-7099
Practice Address - Street 1:1406 SIXTH AVE N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-240-2157
Practice Address - Fax:320-656-7099
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24794207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D81173Medicare UPIN