Provider Demographics
NPI:1316019466
Name:HOLM, WENDY SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:HOLM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 9TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-6756
Mailing Address - Country:US
Mailing Address - Phone:507-529-6610
Mailing Address - Fax:
Practice Address - Street 1:210 9TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-6756
Practice Address - Country:US
Practice Address - Phone:507-529-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2181363A00000X
MN11006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01164698Medicaid
CO01164698Medicaid
CO97318Medicare ID - Type Unspecified