Basic Information
| Provider Information | |||||||||
| NPI: | 1750904462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600154032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185547447 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 DAVIS ST | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602014619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128159660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2020 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.