Provider Demographics
NPI:1942241989
Name:ROZEBOOM, HOLLY LYNN (PAC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
Last Name:ROZEBOOM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3128
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-3128
Mailing Address - Country:US
Mailing Address - Phone:712-239-4702
Mailing Address - Fax:712-239-0616
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1394
Practice Address - Country:US
Practice Address - Phone:712-239-4702
Practice Address - Fax:712-239-0616
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001057363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI9600Medicare ID - Type Unspecified