Provider Demographics
NPI:1861453268
Name:JODON, HOLLY KAY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:KAY
Last Name:JODON
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 1:240 W 11TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1702
Mailing Address - Country:US
Mailing Address - Phone:814-452-2218
Mailing Address - Fax:814-452-4639
Practice Address - Street 1:240 W 11TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1702
Practice Address - Country:US
Practice Address - Phone:814-452-2218
Practice Address - Fax:814-452-4639
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000632L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAR08428Medicare UPIN
146157FTGMedicare PIN