Provider Demographics
NPI:1407626153
Name:SANDBERG, HOLLY (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 STATE HIGHWAY 114 APT 2309
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-2267
Mailing Address - Country:US
Mailing Address - Phone:814-969-1597
Mailing Address - Fax:
Practice Address - Street 1:3901 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7738
Practice Address - Country:US
Practice Address - Phone:814-969-1597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant