Provider Demographics
NPI:1295343887
Name:HOLLOWAY, CARRIE JANE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:JANE
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5209
Mailing Address - Country:US
Mailing Address - Phone:575-622-8170
Mailing Address - Fax:
Practice Address - Street 1:18600 WEDGE PARKWAY
Practice Address - Street 2:NEIL J. REDFIELD BLDG. A, SUITE 104
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511
Practice Address - Country:US
Practice Address - Phone:775-784-4843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64940363A00000X
390200000X
NMPA2021-0094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program