Provider Demographics
NPI:1346299989
Name:HOLBERT, MARC ANDREW
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ANDREW
Last Name:HOLBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARC
Other - Middle Name:A
Other - Last Name:HOLBERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80150-1175
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1950 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3129
Practice Address - Country:US
Practice Address - Phone:303-651-5000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1694363AM0700X
COPA.0001694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO74358081Medicaid
CO350120YWS6Medicare PIN
COC802777Medicare PIN
CO74358081Medicaid