Basic Information
| Provider Information | |||||||||
| NPI: | 1063054278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VON HOLTEN | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 PRENZLER DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617041299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098246658 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 TRINITY LN STE 111 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2019 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085.007292 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 085.007292 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 085.007292 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.