Provider Demographics
NPI:1376722009
Name:HOLT, SHEA RYAN (MD)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:RYAN
Last Name:HOLT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1812
Mailing Address - Country:US
Mailing Address - Phone:817-336-5060
Mailing Address - Fax:817-336-1744
Practice Address - Street 1:2221 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1812
Practice Address - Country:US
Practice Address - Phone:817-336-5060
Practice Address - Fax:817-336-1744
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN9377207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program