Provider Demographics
NPI:1164196986
Name:HOLSTEIN, MARY KATHERINE (MSN-AGACNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:HOLSTEIN
Suffix:
Gender:F
Credentials:MSN-AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 S EASTERN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-7851
Mailing Address - Country:US
Mailing Address - Phone:702-410-5319
Mailing Address - Fax:702-442-1494
Practice Address - Street 1:4445 S EASTERN AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7851
Practice Address - Country:US
Practice Address - Phone:702-410-5319
Practice Address - Fax:702-442-1494
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1048013363LA2100X
NV839696363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1164196986Medicaid