Provider Demographics
NPI:1295104891
Name:HOLMES, SAM RIVER (PA-C)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:RIVER
Last Name:HOLMES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3425
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-0425
Mailing Address - Country:US
Mailing Address - Phone:785-830-0100
Mailing Address - Fax:785-830-0115
Practice Address - Street 1:4921 W 18TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-2090
Practice Address - Country:US
Practice Address - Phone:785-830-0100
Practice Address - Fax:785-830-0115
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS15-01841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant