Provider Demographics
NPI:1023249810
Name:BROCK, HOLLY (PA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:WALKINGTON-BROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 87044
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98687-7044
Mailing Address - Country:US
Mailing Address - Phone:360-258-1787
Mailing Address - Fax:
Practice Address - Street 1:1400 NE 136TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-0993
Practice Address - Country:US
Practice Address - Phone:360-258-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61433590363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant