Provider Demographics
NPI:1518369024
Name:HOLTZ, MICHAEL PAUL (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:HOLTZ
Suffix:
Gender:M
Credentials:FNP-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 224
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-0224
Mailing Address - Country:US
Mailing Address - Phone:660-268-4006
Mailing Address - Fax:660-258-9006
Practice Address - Street 1:624 W LOCKLING ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-2003
Practice Address - Country:US
Practice Address - Phone:660-268-4006
Practice Address - Fax:660-258-9006
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014033136363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1518369024Medicaid
1083088058OtherGROUP NPI ADVANCED MEDICAL EXPRESS CLINIC
1083088058OtherGROUP NPI ADVANCED MEDICAL HOUSE CALL AND TELEMEDICINE, LLC