Provider Demographics
NPI:1902376023
Name:HOLTER, JEFFREY (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HOLTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD # 4S-205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-605-7171
Mailing Address - Fax:
Practice Address - Street 1:10862 CALLE VERDE # S93
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941
Practice Address - Country:US
Practice Address - Phone:619-660-1822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-01
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant