Provider Demographics
NPI:1750366886
Name:HOLLAND, ELIZABETH KOONTZ (PAC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KOONTZ
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:KOONTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-713-5424
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-713-5424
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000101509363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7338641OtherAETNA
NC94676OtherMEDCOST
NC94676OtherMEDCOST
S92561Medicare UPIN
NC2755188Medicare PIN