Provider Demographics
NPI:1417316696
Name:STAHL, HOLLIS TAGGART (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLIS
Middle Name:TAGGART
Last Name:STAHL
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 1:5651 COPLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7903
Mailing Address - Country:US
Mailing Address - Phone:858-262-6344
Mailing Address - Fax:858-626-2032
Practice Address - Street 1:5525 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3009
Practice Address - Country:US
Practice Address - Phone:619-644-6705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant