Provider Demographics
NPI:1366929887
Name:HOLVERSON, ALEXIS S (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:S
Last Name:HOLVERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MONTE VISTA AVE STE 190
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-6600
Mailing Address - Country:US
Mailing Address - Phone:909-865-9501
Mailing Address - Fax:909-469-2119
Practice Address - Street 1:1601 MONTE VISTA AVE STE 190
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-6600
Practice Address - Country:US
Practice Address - Phone:909-865-9501
Practice Address - Fax:909-469-2119
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366929887Medicaid