Provider Demographics
NPI:1770030462
Name:OLIVER, HOLLY (PA-C)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18059 HIGHWAY 105 W STE 130
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-5002
Mailing Address - Country:US
Mailing Address - Phone:936-582-5620
Mailing Address - Fax:936-582-5621
Practice Address - Street 1:18059 HIGHWAY 105 W STE 130
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-5002
Practice Address - Country:US
Practice Address - Phone:936-582-5620
Practice Address - Fax:936-582-5621
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX364873501Medicaid