Provider Demographics
NPI:1780855296
Name:DYER, HOLLY L (PAC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:L
Last Name:DYER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:L
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1249 15TH ST
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3662
Mailing Address - Country:US
Mailing Address - Phone:304-691-1000
Mailing Address - Fax:304-691-1063
Practice Address - Street 1:1249 15TH ST
Practice Address - Street 2:SUITE 3000
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3662
Practice Address - Country:US
Practice Address - Phone:304-691-1000
Practice Address - Fax:304-691-1063
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI002020293OtherBLUE CROSS
MI002020293OtherBLUE CROSS
WVDYPA30634Medicare PIN