Provider Demographics
NPI:1710638218
Name:HARRISON, HOLLY REBECCA (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:REBECCA
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:REBECCA
Other - Last Name:REESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:405 E NIFONG BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3708
Practice Address - Country:US
Practice Address - Phone:573-884-0146
Practice Address - Fax:573-884-1066
Is Sole Proprietor?:No
Enumeration Date:2022-01-16
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1172455363A00000X
MO2022003496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220108653Medicaid