Provider Demographics
NPI:1134361520
Name:HOLBACK, PETER D (PA-C)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:D
Last Name:HOLBACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 EASTERN AVE
Mailing Address - Street 2:A BLDG, 5TH FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-2735
Mailing Address - Country:US
Mailing Address - Phone:410-550-4335
Mailing Address - Fax:410-550-1274
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:A BLDG, 5TH FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-4335
Practice Address - Fax:410-550-1274
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC-1037363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical