Provider Demographics
NPI:1619475969
Name:HOLLY, LUKE BRANDON (PA-C)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:BRANDON
Last Name:HOLLY
Suffix:
Gender:M
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 1:124 NAVAHO TRL
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49620-9527
Mailing Address - Country:US
Mailing Address - Phone:231-878-8310
Mailing Address - Fax:
Practice Address - Street 1:124 NAVAHO TRL
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:MI
Practice Address - Zip Code:49620-9527
Practice Address - Country:US
Practice Address - Phone:231-878-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008553363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant