Provider Demographics
NPI:1316020563
Name:HOLT, PAUL KELLY (ARNP)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:KELLY
Last Name:HOLT
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7626
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7626
Mailing Address - Country:US
Mailing Address - Phone:270-443-2900
Mailing Address - Fax:270-443-7122
Practice Address - Street 1:2603 KENTUCKY AVENUE
Practice Address - Street 2:SUITE 303
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003
Practice Address - Country:US
Practice Address - Phone:270-443-2900
Practice Address - Fax:270-443-7122
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2980P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78014891Medicaid
KY354856OtherANTHEM INDIVIDUAL
Q36645Medicare UPIN
KY0933404Medicare ID - Type Unspecified