Provider Demographics
NPI:1417943283
Name:HOLDER, PATRICIA T
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:T
Last Name:HOLDER
Suffix:
Gender:F
Credentials:
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 69
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-0002
Mailing Address - Country:US
Mailing Address - Phone:706-258-4040
Mailing Address - Fax:706-258-4041
Practice Address - Street 1:11 OVERVIEW DR
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6611
Practice Address - Country:US
Practice Address - Phone:706-258-4040
Practice Address - Fax:706-258-4041
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN030209367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA339841OtherWELLCARE
GA00559776CMedicaid
GA10039454OtherAMERIGROUP
GA054224OtherBLUE CROSS BLUE SHIELD
GA43ZCBMT06Medicare PIN