Provider Demographics
NPI:1588396378
Name:HOLT, VICTORIA HAYNES (PA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:HAYNES
Last Name:HOLT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5480 GOODMAN RD STE 1
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7902
Practice Address - Country:US
Practice Address - Phone:662-874-6507
Practice Address - Fax:662-932-8197
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSPA00746363A00000X
TN5678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant