Provider Demographics
NPI:1336561737
Name:HOLT, PATRICK LAVERN
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:LAVERN
Last Name:HOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 N FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-1268
Mailing Address - Country:US
Mailing Address - Phone:641-421-8640
Mailing Address - Fax:641-421-8640
Practice Address - Street 1:1454 N FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1268
Practice Address - Country:US
Practice Address - Phone:641-421-8640
Practice Address - Fax:641-421-8640
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-20
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1-17-010888 M335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier