Provider Demographics
NPI:1861615528
Name:HOLM, REBECCA (PAC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HOLM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:KONEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:10011 WINDLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-2148
Mailing Address - Country:US
Mailing Address - Phone:979-733-2281
Mailing Address - Fax:
Practice Address - Street 1:2222 WELBORN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-3924
Practice Address - Country:US
Practice Address - Phone:214-559-7830
Practice Address - Fax:214-559-8383
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03306363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA03306OtherLICENSE