Provider Demographics
NPI:1467478396
Name:HOLMES, RICHARD L JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
Last Name:HOLMES
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11010 N DESERT VIEW LN
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1787
Mailing Address - Country:US
Mailing Address - Phone:928-600-7630
Mailing Address - Fax:928-600-7630
Practice Address - Street 1:1810 MESQUITE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5886
Practice Address - Country:US
Practice Address - Phone:928-453-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7129207P00000X, 363A00000X
PAOA003194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
S94111Medicare UPIN