Provider Demographics
NPI:1619067931
Name:HOLMQUIST, PAUL ALLEN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ALLEN
Last Name:HOLMQUIST
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17760 LAYTON PATH
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5214
Mailing Address - Country:US
Mailing Address - Phone:952-892-5529
Mailing Address - Fax:
Practice Address - Street 1:625 E NICOLLET BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6734
Practice Address - Country:US
Practice Address - Phone:952-435-0343
Practice Address - Fax:952-435-0344
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN955230800Medicaid