Provider Demographics
NPI:1669200812
Name:HOLMES, ELIZABETH A (AGNP-BC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:HOLMES
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-2127
Mailing Address - Country:US
Mailing Address - Phone:415-999-2792
Mailing Address - Fax:
Practice Address - Street 1:314 NE 19TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2829
Practice Address - Country:US
Practice Address - Phone:415-999-2792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95192567163W00000X
OR10018561163W00000X, 363L00000X
CANP95028849363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse