Provider Demographics
NPI:1497194781
Name:GAULT, HOLLY RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:RENEE
Last Name:GAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3011 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-2546
Mailing Address - Country:US
Mailing Address - Phone:620-231-9873
Mailing Address - Fax:620-231-5062
Practice Address - Street 1:3011 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-2546
Practice Address - Country:US
Practice Address - Phone:620-231-9873
Practice Address - Fax:620-231-5062
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2013017864207Q00000X
KS0439378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine