Provider Demographics
NPI:1295896751
Name:HOLST, STEPHEN WILSON (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WILSON
Last Name:HOLST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 WEST DOW STREET
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-672-1806
Mailing Address - Fax:307-672-1808
Practice Address - Street 1:340 WEST DOW STREET
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801
Practice Address - Country:US
Practice Address - Phone:307-672-1806
Practice Address - Fax:307-672-1808
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5434A208800000X
CO2157208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY109407600Medicaid
WY306592OtherBXBS
E80847Medicare UPIN
WY109407600Medicaid