Basic Information
| Provider Information | |||||||||
| NPI: | 1255332375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLSTEAD | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195895161 | ||||||||
| FaxNumber: | 7195895722 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193835900 | ||||||||
| FaxNumber: | 7193836533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008063 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3650 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.