Provider Demographics
NPI:1912540592
Name:HOLIWELL, JUSTIN PATRICK
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PATRICK
Last Name:HOLIWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4154 SAN MARTIN WAY UNIT B
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110-1430
Mailing Address - Country:US
Mailing Address - Phone:661-428-4782
Mailing Address - Fax:
Practice Address - Street 1:400 W PUEBLO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4353
Practice Address - Country:US
Practice Address - Phone:805-682-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CAPA58237363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty