Provider Demographics
NPI:1780664284
Name:HOLTAN, SHERNAN G (MD)
Entity Type:Individual
Prefix:
First Name:SHERNAN
Middle Name:G
Last Name:HOLTAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:612-625-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46758207R00000X, 207RH0000X
ORMD154732207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN530002900Medicaid
WI35177800Medicaid
MNP00639250OtherMEDICARE RAILROAD
IAENROLLEDMedicaid
WI35177800Medicaid
MN530002900Medicaid
MN110009725Medicare PIN