Provider Demographics
NPI:1134744220
Name:HOLBROOK, KAITLYN MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MICHELLE
Last Name:HOLBROOK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:MICHELLE
Other - Last Name:HOLBROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8614
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD STE 310
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4281
Practice Address - Country:US
Practice Address - Phone:864-455-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SC3604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4263PAMedicaid