Provider Demographics
NPI:1023191574
Name:THOMPSON, HOLLY GWEN (PAC)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:GWEN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:
Practice Address - Street 1:26 ELM STREET
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:WV
Practice Address - Zip Code:25213
Practice Address - Country:US
Practice Address - Phone:304-586-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-002246363A00000X
WV1062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1071915OtherWV DWC
WV001718835OtherWV BCBS
WV24837Medicare PIN
WV001718835OtherWV BCBS
WV24835Medicare PIN
S070530Medicare UPIN