Provider Demographics
NPI: | 1619411709 |
---|---|
Name: | HOLLIS, BRETT FRASIER (NP) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | BRETT |
Middle Name: | FRASIER |
Last Name: | HOLLIS |
Suffix: | |
Gender: | M |
Credentials: | NP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 711 |
Mailing Address - Street 2: | |
Mailing Address - City: | SALEM |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 08079-0711 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 907-903-0420 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 142 ROADSTOWN RD |
Practice Address - Street 2: | |
Practice Address - City: | BRIDGETON |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08302-5798 |
Practice Address - Country: | US |
Practice Address - Phone: | 907-903-0420 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2016-12-08 |
Last Update Date: | 2016-12-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
DE | LP-0000187 | 363LA2200X, 363LG0600X, 363LP2300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No | 363LG0600X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |