Provider Demographics
NPI:1164866372
Name:BEAN, HOLLY ROSE (DO)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ROSE
Last Name:BEAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 SASSAFRAS ST STE 310
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2721
Mailing Address - Country:US
Mailing Address - Phone:814-456-6194
Mailing Address - Fax:814-452-5777
Practice Address - Street 1:2314 SASSAFRAS ST STE 310
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502
Practice Address - Country:US
Practice Address - Phone:814-456-6194
Practice Address - Fax:814-452-5777
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS019486207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103240095Medicaid