Individual
NICHOLAS RAY VON HOLTEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1111 TRINITY LN STE 111, BLOOMINGTON, IL 61704-8112
(309) 663-6461
Mailing address
21 PRENZLER DR, BLOOMINGTON, IL 61704-1299
(309) 824-6658
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085.007292
IL
363AM0700X
Medical Physician Assistant
085.007292
IL
363AS0400X
Surgical Physician Assistant
085.007292
IL
Other
Enumeration date
10/09/2019
Last updated
10/09/2019
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