Provider Demographics
NPI:1720421779
Name:HOLMES, RANDI LEE (PA)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:LEE
Last Name:HOLMES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5762 W 8055 S APT M106
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-3137
Mailing Address - Country:US
Mailing Address - Phone:951-205-1052
Mailing Address - Fax:
Practice Address - Street 1:5171 S COTTONWOOD ST STE 740
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5705
Practice Address - Country:US
Practice Address - Phone:801-507-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA363AM0700X
UT11573235-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical