Provider Demographics
NPI:1508104589
Name:GLOVER, HOLLY SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:SUE
Last Name:GLOVER
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 1:1935 MEDICAL DISTRICT DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7701
Mailing Address - Country:US
Mailing Address - Phone:214-456-8000
Mailing Address - Fax:214-456-8006
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-8000
Practice Address - Fax:214-456-8006
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
TXPA08301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX319842601Medicaid
TX319842602Medicaid
TX280000YP79Medicare PIN
TX280000YP78Medicare PIN