Provider Demographics
NPI:1114440195
Name:HOLLIS, WARDELL BRIAN (NP)
Entity Type:Individual
Prefix:MR
First Name:WARDELL
Middle Name:BRIAN
Last Name:HOLLIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W SUNSET RD STE 400
Mailing Address - Street 2:
Mailing Address - City:ALAMO HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1772
Mailing Address - Country:US
Mailing Address - Phone:844-824-8775
Mailing Address - Fax:281-648-2200
Practice Address - Street 1:430 W SUNSET RD STE 400
Practice Address - Street 2:
Practice Address - City:ALAMO HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:78209-1772
Practice Address - Country:US
Practice Address - Phone:844-824-8775
Practice Address - Fax:281-648-2200
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134080363LP0808X
TX789660363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX402733602Medicaid