Provider Demographics
NPI:1922407774
Name:HUTCHINSON, HOLLY (PA-C, LD, RD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:HUTCHINSON
Suffix:
Gender:F
Credentials:PA-C, LD, RD
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA, RD
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8752
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR STE 500
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6305
Practice Address - Country:US
Practice Address - Phone:208-706-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-783133V00000X
IDPA1649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered