Provider Demographics
NPI:1457335747
Name:ANDERSON, HOLLY (PA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:ANDERSON
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:P.O BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 EASTLAKE AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-4405
Practice Address - Country:US
Practice Address - Phone:206-288-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60043081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1069039Medicaid
MNMH9041043467OtherPPO
FMHP50102OtherHEALTH PARTNERS
MN465R5ANOtherBLUE PLUS
MN01-21435OtherMEDICA
FM465R5ANOtherBCBS
FM2307523OtherARAZ
FM10091OtherAVERA
MN958105700Medicaid
FM2307523OtherARAZ
MN970002143Medicare NSC
MN970002143Medicare ID - Type UnspecifiedMEDICARE