Provider Demographics
NPI:1568432748
Name:HOLTHAM, MARY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:HOLTHAM
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 1:4730 N HABANA AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7148
Mailing Address - Country:US
Mailing Address - Phone:813-549-2134
Mailing Address - Fax:813-864-4436
Practice Address - Street 1:595 N COURTENAY PKWY STE 206
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4851
Practice Address - Country:US
Practice Address - Phone:321-735-6220
Practice Address - Fax:321-507-4638
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3644363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA3644OtherSTATE LICENSE NUMBER
FLPA3644OtherSTATE LICENSE NUMBER
FLS70839Medicare UPIN