Provider Demographics
NPI:1497770630
Name:HOLLOWAY, LISSA S (PA)
Entity Type:Individual
Prefix:
First Name:LISSA
Middle Name:S
Last Name:HOLLOWAY
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 1:532 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:BRITT
Mailing Address - State:IA
Mailing Address - Zip Code:50423-1227
Mailing Address - Country:US
Mailing Address - Phone:641-843-5050
Mailing Address - Fax:641-843-5051
Practice Address - Street 1:532 1ST ST NW
Practice Address - Street 2:
Practice Address - City:BRITT
Practice Address - State:IA
Practice Address - Zip Code:50423-1227
Practice Address - Country:US
Practice Address - Phone:641-843-5050
Practice Address - Fax:641-843-5051
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA42917OtherWELLMARK - KANAWHA CLINIC
IA42915OtherWELLMARK BRITT CLINIC
IA42915OtherWELLMARK BRITT CLINIC
IA42917OtherWELLMARK - KANAWHA CLINIC