Provider Demographics
NPI:1649341892
Name:HOLGORSEN, KELLE N (PA-C, MMS)
Entity type:Individual
Prefix:
First Name:KELLE
Middle Name:N
Last Name:HOLGORSEN
Suffix:
Gender:F
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5611
Mailing Address - Country:US
Mailing Address - Phone:704-563-5007
Mailing Address - Fax:
Practice Address - Street 1:4101 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5611
Practice Address - Country:US
Practice Address - Phone:704-563-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2025-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102714207Q00000X
CO1482363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical