Basic Information
| Provider Information | |||||||||
| NPI: | 1912597063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLBORN | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3428 S 113TH ST APT 5 | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532273935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629140874 | ||||||||
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| Practice Location | |||||||||
| Address1: | 725 AMERICAN AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629281000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2021 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 10588 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.