Provider Demographics
NPI:1396889127
Name:HOLDER, ETHEL (PA)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:HOLDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:12001 AVALON LAKE DR APT 222
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7378
Mailing Address - Country:US
Mailing Address - Phone:347-475-4503
Mailing Address - Fax:
Practice Address - Street 1:1307 E OSCEOLA PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1605
Practice Address - Country:US
Practice Address - Phone:844-665-4827
Practice Address - Fax:855-852-1974
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY009214363A00000X
FLPA9109641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant