Provider Demographics
NPI:1790224533
Name:DEAVER, HOLLY LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:LAUREN
Last Name:DEAVER
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 1:410 TEMPO TRL
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:NC
Mailing Address - Zip Code:28574-8481
Mailing Address - Country:US
Mailing Address - Phone:828-400-5095
Mailing Address - Fax:
Practice Address - Street 1:308 DOLPHIN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5266
Practice Address - Country:US
Practice Address - Phone:910-346-2273
Practice Address - Fax:910-346-1907
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant