Provider Demographics
NPI:1710968375
Name:HOLTER, BROOKLEY VALENTINE (PAC)
Entity Type:Individual
Prefix:
First Name:BROOKLEY
Middle Name:VALENTINE
Last Name:HOLTER
Suffix:
Gender:F
Credentials:PAC
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 8500, LOCKBOX 7642
Mailing Address - Street 2:SHRINER'S HOSPITALS FOR CHILDREN PORTLAND
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:813-281-8115
Mailing Address - Fax:813-281-8656
Practice Address - Street 1:3101 SW SAM JACKSON PARK RD
Practice Address - Street 2:SHRINER'S HOSPITAL FOR CHILDREN
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-221-3428
Practice Address - Fax:503-221-3490
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00818363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080727006OtherREGENCE BCBS
P00186774OtherRR MEDICARE
WA0192176OtherWA LABOR INDUSTRIES
P80105Medicare UPIN
130214Medicare ID - Type Unspecified