Provider Demographics
NPI:1184958787
Name:HOLT, HEATHER LEIGH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEIGH
Last Name:HOLT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LEIGH
Other - Last Name:HOLLIDAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:807 W CRAFT ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1137
Mailing Address - Country:US
Mailing Address - Phone:618-546-5052
Mailing Address - Fax:618-544-2094
Practice Address - Street 1:807 W CRAFT ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1137
Practice Address - Country:US
Practice Address - Phone:618-546-5052
Practice Address - Fax:618-544-2094
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1088888OtherNCCPA CERTIFICATION
IL085.003564OtherPHYSICIAN ASSISTANT LICENSE
IL1088888OtherNCCPA CERTIFICATION