Provider Demographics
NPI:1396742896
Name:HOLTER, TODD JERAMIE (PAC)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:JERAMIE
Last Name:HOLTER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2619
Practice Address - Country:US
Practice Address - Phone:952-831-8742
Practice Address - Fax:952-977-3459
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1684363AS0400X
MN9820363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P99044Medicare UPIN
WI56080-0022Medicare PIN
P99044Medicare UPIN
MN0572890001Medicare NSC
MN970001768Medicare ID - Type UnspecifiedMN MEDICARE NUM
WI49128-0021Medicare PIN
MN153413100Medicaid