Provider Demographics
NPI:1114180122
Name:HOLLOWAY, MARCY N (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:N
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-750-3425
Mailing Address - Fax:702-750-3434
Practice Address - Street 1:8670 W CHEYENNE AVE
Practice Address - Street 2:UNIT1
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7456
Practice Address - Country:US
Practice Address - Phone:702-750-3425
Practice Address - Fax:702-750-3434
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1114180122Medicaid
NVV110611Medicare PIN