Provider Demographics
NPI:1417096058
Name:HOLTORF, KRAIG M (PA-C)
Entity Type:Individual
Prefix:
First Name:KRAIG
Middle Name:M
Last Name:HOLTORF
Suffix:
Gender:M
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:3050 E RIVER BLUFF BLVD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-8807
Practice Address - Country:US
Practice Address - Phone:417-829-5610
Practice Address - Fax:417-829-5588
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002023840363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO132300306Medicare PIN
MO000085541Medicare PIN
MOP73656Medicare UPIN