Provider Demographics
NPI:1487637674
Name:HOLTZ, STACY D (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:D
Last Name:HOLTZ
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 1:245 JEREMY SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2360
Mailing Address - Country:US
Mailing Address - Phone:203-267-5212
Mailing Address - Fax:203-267-5212
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:SUITE 7004
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06721
Practice Address - Country:US
Practice Address - Phone:203-573-7307
Practice Address - Fax:203-573-6555
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000716363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S86244Medicare UPIN