Provider Demographics
NPI:1699178897
Name:BUFFALO LAKE MEDICAL, PLLC
Entity Type:Organization
Organization Name:BUFFALO LAKE MEDICAL, PLLC
Other - Org Name:HOLDEN HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OF GROUP
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONNITA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:919-842-5566
Mailing Address - Street 1:181 MITTIE HADDOCK DR.
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:NC
Mailing Address - Zip Code:28326
Mailing Address - Country:US
Mailing Address - Phone:919-842-5566
Mailing Address - Fax:919-375-2048
Practice Address - Street 1:181 MITTIE HADDOCK DR.
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326
Practice Address - Country:US
Practice Address - Phone:919-842-5566
Practice Address - Fax:919-375-2048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1100X
NC197607363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearchGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty