Provider Demographics
NPI:1336156868
Name:LINDHOLM, GREG SCOTT (PA)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:SCOTT
Last Name:LINDHOLM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:605 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:LINDSBORG
Mailing Address - State:KS
Mailing Address - Zip Code:67456-2328
Mailing Address - Country:US
Mailing Address - Phone:785-227-3371
Mailing Address - Fax:785-227-3004
Practice Address - Street 1:605 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:LINDSBORG
Practice Address - State:KS
Practice Address - Zip Code:67456-2328
Practice Address - Country:US
Practice Address - Phone:785-227-3371
Practice Address - Fax:785-227-3004
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00298363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100003220GMedicaid
R30939Medicare UPIN
KSP00022811OtherRAILROAD MEDICARE