Provider Demographics
NPI:1366493504
Name:METZEROTT, HOLLY (CRNA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:METZEROTT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W WEST ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-3840
Mailing Address - Country:US
Mailing Address - Phone:704-576-4476
Mailing Address - Fax:
Practice Address - Street 1:116 W WEST ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3840
Practice Address - Country:US
Practice Address - Phone:704-576-4476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC045314367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051508Medicaid
NC260887MMedicare ID - Type Unspecified