Provider Demographics
NPI:1376507541
Name:SHORT, HOLLY DAWN (PA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:DAWN
Last Name:SHORT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1122
Mailing Address - Country:US
Mailing Address - Phone:806-792-4329
Mailing Address - Fax:806-792-9466
Practice Address - Street 1:4110 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1122
Practice Address - Country:US
Practice Address - Phone:806-792-4329
Practice Address - Fax:806-792-9466
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C6695Medicare ID - Type Unspecified