NPIMap

Individual provider Active NPI

Victoria Haynes Holt, PA

  • Physician Assistant
  • Olive Branch, MS
National Provider Identifier
1588396378
Registry record updated Mar 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA00746 Issued in MS
Practice address
5480 Goodman Rd Ste 1
Olive Branch, MS 38654-7902
Phone
(662) 874-6507
Fax
(662) 932-8197
NPI assigned
Jun 29, 2022
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 19, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA00746 MS Primary
Physician Assistant 363A00000X 5678 TN

Addresses

Primary practice location

5480 Goodman Rd Ste 1
Olive Branch, MS 38654-7902

Mailing address

1211 Union Ave Ste 330
Memphis, TN 38104-6655

Other practice location 1

1300 Wesley Dr
Memphis, TN 38116-6426
Phone (901) 516-5741

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN, MS2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20231009001408 TN Practitioner - Physician Assistant 6204281439 Reassigns benefits to 1 organization
I20240423003832 MS Practitioner - Physician Assistant 6204281439 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Primary Care Group, LLCGroup PAC ID 0941480131, 108 clinicians

Practice addresses (Care Compare)

5480 Goodman Rd
Suite 1
Olive Branch, MS 38654-7902
Phone (662) 874-6507

7235 Hacks Cross Rd
Olive Branch, MS 38654-4213
Phone (662) 893-7878

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
5678TNMDDental Hygienist

Interoperability endpoints

  • Direct secure messaging: vholt34716@mlh.direct-ci.com

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1656460800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1710806400000",
    "number": "1588396378",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1211 UNION AVE STE 330",
            "city": "MEMPHIS",
            "state": "TN",
            "postal_code": "381046655"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5480 GOODMAN RD STE 1",
            "city": "OLIVE BRANCH",
            "state": "MS",
            "postal_code": "386547902",
            "telephone_number": "662-874-6507",
            "fax_number": "662-932-8197"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1300 Wesley Dr",
            "address_purpose": "LOCATION",
            "city": "Memphis",
            "state": "TN",
            "postal_code": "381166426",
            "country_code": "US",
            "telephone_number": "901-516-5741",
            "fax_number": "901-516-5986",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "HOLT",
        "first_name": "VICTORIA",
        "middle_name": "HAYNES",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-06-29",
        "last_updated": "2024-03-19",
        "certification_date": "2024-03-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MS",
            "license": "PA00746",
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "TN",
            "license": "5678",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Olive Branch, MS

Sources for this page

Verify at the official NPI Registry.