Basic Information
| Provider Information | |||||||||
| NPI: | 1477539906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLSBEKE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 336 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061172510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602324891 | ||||||||
| FaxNumber: | 8602361016 | ||||||||
| Practice Location | |||||||||
| Address1: | 336 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061172510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602324891 | ||||||||
| FaxNumber: | 8602361016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 12/19/2013 | ||||||||
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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 | 000685 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 000685 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1477539906 | 01 | CT | NPI | OTHER |