Provider Demographics
NPI:1912928359
Name:HOLMES, VIRGINIA C (PA)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:C
Last Name:HOLMES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7630 N BEACH ST STE 140
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-3016
Mailing Address - Country:US
Mailing Address - Phone:817-281-2977
Mailing Address - Fax:817-788-2530
Practice Address - Street 1:7630 N BEACH ST STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3016
Practice Address - Country:US
Practice Address - Phone:817-281-2977
Practice Address - Fax:817-788-2530
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004523363A00000X
TXPA05492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX326751001Medicaid
TXTXB107139Medicare PIN
GA97WCHHBMedicare PIN
TX326751001Medicaid