1417973066 NPI number — KRYSTINA MICHELLE HOLLORAN P.A.-C

Table of content: KRYSTINA MICHELLE HOLLORAN P.A.-C (NPI 1417973066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417973066 NPI number — KRYSTINA MICHELLE HOLLORAN P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLORAN
Provider First Name:
KRYSTINA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DANGEL
Provider Other First Name:
KRYSTINA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417973066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 S CLEARVIEW AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85209-3378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-988-9108
Provider Business Mailing Address Fax Number:
480-813-4460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3160 E QUEEN CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85297-8402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-889-1157
Provider Business Practice Location Address Fax Number:
480-889-1160
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  3459 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 125538 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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