Provider Demographics
NPI:1255332375
Name:HOLSTEAD, ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:HOLSTEAD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2290
Mailing Address - Country:US
Mailing Address - Phone:719-589-5161
Mailing Address - Fax:719-589-5722
Practice Address - Street 1:1012 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2101
Practice Address - Country:US
Practice Address - Phone:719-383-5900
Practice Address - Fax:719-383-6533
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008063363A00000X
CO3650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0553Medicare ID - Type Unspecified
NYP34139Medicare UPIN