Provider Demographics
NPI:1205834991
Name:HOLT, CHARLES K
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:K
Last Name:HOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12250 E ILIFF AVE
Mailing Address - Street 2:#300
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-6318
Mailing Address - Country:US
Mailing Address - Phone:720-524-1550
Mailing Address - Fax:720-524-1551
Practice Address - Street 1:12250 E ILIFF AVE
Practice Address - Street 2:#300
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-6318
Practice Address - Country:US
Practice Address - Phone:720-524-1550
Practice Address - Fax:720-524-1551
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03679363A00000X
COPA0004528363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3452Medicare PIN