Provider Demographics
NPI:1275738197
Name:HOLMAN, JEREMY R (PA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:R
Last Name:HOLMAN
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 1:2200 E PARRISH AVE
Mailing Address - Street 2:BLDG D SUITE 100
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-316-9795
Mailing Address - Fax:
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLDG D SUITE 100
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-688-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC020363A00000X
IN99027503A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000526456OtherANTHEM
IN202280XMedicare PIN
KY0649920Medicare PIN