Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | G76027 | CA |
N | 207VX0000X | Obstetrician | G76027 | CA |
NPI | 1164416764 |
---|---|
Provider Name | David Glenn Holst |
First Address | Mount Shasta, CA 96067-0339 |
Second Address | Mount Shasta, CA 96067-2137 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2005 |
Last Update Date | 19/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G760270 | (05) | CA |
080080840 | RAILROAD MEDICARE (01) | |
F66555 | (02) |