Provider Demographics
NPI:1497819098
Name:HOLLOWAY, WADE (PAC)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 JODECO RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4953
Mailing Address - Country:US
Mailing Address - Phone:678-284-6300
Mailing Address - Fax:678-284-6282
Practice Address - Street 1:259 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3769
Practice Address - Country:US
Practice Address - Phone:770-957-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant