Provider Demographics
NPI:1255423711
Name:COKER, HOLLY E (PA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:E
Last Name:COKER
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:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-920-6400
Mailing Address - Fax:
Practice Address - Street 1:3614 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3352
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8371NCOtherBCBS
TX183514201Medicaid
TX183514204Medicaid
TX183514202Medicaid
TX814N37OtherBCBS
TXP01142303OtherRAILROAD MEDICARE
TXQ48426Medicare UPIN
TXP01142303OtherRAILROAD MEDICARE
TX183514201Medicaid
TX8L23978Medicare PIN