Provider Demographics
NPI:1093785321
Name:HOLDER, DEBORAH DEE (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:DEE
Last Name:HOLDER
Suffix:
Gender:F
Credentials:PA-C
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 1044
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-1044
Mailing Address - Country:US
Mailing Address - Phone:918-274-8555
Mailing Address - Fax:918-274-8556
Practice Address - Street 1:4115 REDDEN
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-9192
Practice Address - Country:US
Practice Address - Phone:918-825-7555
Practice Address - Fax:918-825-7556
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK660363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100162560DMedicaid
P00997563OtherMEDICARE RAILROAD
OKR10987Medicare UPIN
OK248519606Medicare PIN
OK100162560DMedicaid
P00997563OtherMEDICARE RAILROAD