Provider Demographics
NPI:1104197318
Name:WOLTERS, HOLLY ANN (PA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:WOLTERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:ANN
Other - Last Name:FORTKAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 713130
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-0001
Mailing Address - Country:US
Mailing Address - Phone:937-415-9100
Mailing Address - Fax:937-415-9191
Practice Address - Street 1:4160 LITTLE YORK RD
Practice Address - Street 2:SUITE 10
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5800
Practice Address - Country:US
Practice Address - Phone:937-415-9100
Practice Address - Fax:937-415-9191
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP01170703OtherRR MEDICARE
OH0071994Medicaid
OH0071994Medicaid