Provider Demographics
NPI:1558514612
Name:BEARDSLEY, HOLLY (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BEARDSLEY
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 1:1617 WESTCLIFF DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5524
Mailing Address - Country:US
Mailing Address - Phone:949-515-4111
Mailing Address - Fax:949-515-0318
Practice Address - Street 1:1617 WESTCLIFF DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5524
Practice Address - Country:US
Practice Address - Phone:949-515-4111
Practice Address - Fax:949-515-0318
Is Sole Proprietor?:No
Enumeration Date:2008-11-02
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACJ671YOtherMEDICARE PTAN