Provider Demographics
NPI:1629728464
Name:HOLT, MICHAEL LASHANE (APRN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LASHANE
Last Name:HOLT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11024 W 835 RD
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-6340
Mailing Address - Country:US
Mailing Address - Phone:918-616-1111
Mailing Address - Fax:
Practice Address - Street 1:1400 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3324
Practice Address - Country:US
Practice Address - Phone:918-458-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK205318207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine