Provider Demographics
NPI:1104840487
Name:HOLT, ALAN D (CRNA)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:D
Last Name:HOLT
Suffix:
Gender:M
Credentials:CRNA
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 403
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-0403
Mailing Address - Country:US
Mailing Address - Phone:208-523-4906
Mailing Address - Fax:
Practice Address - Street 1:44 N 1ST E
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1326
Practice Address - Country:US
Practice Address - Phone:208-852-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-26367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00398960OtherRAILROAD MEDICARE
ID004368700Medicaid