Provider Demographics
NPI:1346326204
Name:HOLMSTROM, TIMOTHY ELI (MS, PA-C, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ELI
Last Name:HOLMSTROM
Suffix:
Gender:M
Credentials:MS, PA-C, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 SE BISHOP BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5517
Mailing Address - Country:US
Mailing Address - Phone:509-332-2828
Mailing Address - Fax:509-334-7474
Practice Address - Street 1:825 SE BISHOP BLVD STE 120
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5517
Practice Address - Country:US
Practice Address - Phone:509-332-2828
Practice Address - Fax:509-334-7474
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
WAPA60197224363AM0700X
WAPA 60197224363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical