Provider Demographics
NPI:1427594381
Name:HOLLEY, KATRINA JACKSON (PA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:JACKSON
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:JADE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1400 HOSPITAL PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6928
Mailing Address - Country:US
Mailing Address - Phone:817-684-2700
Mailing Address - Fax:817-684-2709
Practice Address - Street 1:1604 HOSPITAL PKWY STE 501
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6932
Practice Address - Country:US
Practice Address - Phone:817-684-2700
Practice Address - Fax:817-684-2709
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11078363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX556403YKPWMedicare PIN
TX556403YKQLMedicare PIN