Provider Demographics
NPI:1528466984
Name:HOLMES, VERNON JR
Entity type:Individual
Prefix:
First Name:VERNON
Middle Name:
Last Name:HOLMES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8424 E SHEA BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8424 E SHEA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6662
Practice Address - Country:US
Practice Address - Phone:480-256-1520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ159595367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered