Provider Demographics
NPI:1508932450
Name:HOLMAN, MICKEL A (PA)
Entity Type:Individual
Prefix:
First Name:MICKEL
Middle Name:A
Last Name:HOLMAN
Suffix:
Gender:M
Credentials:PA
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 4522
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-4522
Mailing Address - Country:US
Mailing Address - Phone:318-518-8499
Mailing Address - Fax:
Practice Address - Street 1:207 DAVENPORT
Practice Address - Street 2:
Practice Address - City:MER ROUGE
Practice Address - State:LA
Practice Address - Zip Code:71261
Practice Address - Country:US
Practice Address - Phone:318-647-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPA.200114OtherLICENSE NUMBER