Basic Information
| Provider Information | |||||||||
| NPI: | 1710968375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLTER | ||||||||
| FirstName: | BROOKLEY | ||||||||
| MiddleName: | VALENTINE | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500, LOCKBOX 7642 | ||||||||
| Address2: | SHRINER'S HOSPITALS FOR CHILDREN PORTLAND | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191787642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818115 | ||||||||
| FaxNumber: | 8132818656 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 SW SAM JACKSON PARK RD | ||||||||
| Address2: | SHRINER'S HOSPITAL FOR CHILDREN | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032213428 | ||||||||
| FaxNumber: | 5032213490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA00818 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 080727006 | 01 | OR | REGENCE BCBS | OTHER | P00186774 | 01 | RR MEDICARE | OTHER | 0192176 | 01 | WA | WA LABOR INDUSTRIES | OTHER |