Provider Demographics
NPI:1932139854
Name:HOLDERBAUM-DOBER, BARBARA L (PA)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:L
Last Name:HOLDERBAUM-DOBER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 DRIVING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1057
Mailing Address - Country:US
Mailing Address - Phone:315-359-2640
Mailing Address - Fax:
Practice Address - Street 1:1208 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1057
Practice Address - Country:US
Practice Address - Phone:315-359-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15754363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ40107Medicare UPIN
CA0PA157541Medicare PIN