Provider Demographics
NPI:1588663165
Name:HOLTGRAVE, THOMAS WILLIAM (APN)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:HOLTGRAVE
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 N BUS US HWY 65
Mailing Address - Street 2:STE. 504
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-4500
Mailing Address - Country:US
Mailing Address - Phone:417-335-2080
Mailing Address - Fax:417-336-3583
Practice Address - Street 1:545 N BUS US HWY 65
Practice Address - Street 2:STE. 504
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-4500
Practice Address - Country:US
Practice Address - Phone:417-335-2080
Practice Address - Fax:417-336-3583
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO066289363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423691567Medicaid
Q34418Medicare UPIN
MO423691567Medicaid
823443798Medicare ID - Type Unspecified