Provider Demographics
NPI:1952427924
Name:HOLLINGSWORTH, CHARLIE (PA)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:HOLLINGSWORTH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WEST 4TH STREET
Mailing Address - Street 2:MOUNT VERNON NEIGHBORHOOD HEALTH CENTER
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550
Mailing Address - Country:US
Mailing Address - Phone:914-699-7200
Mailing Address - Fax:914-699-0837
Practice Address - Street 1:107 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-4002
Practice Address - Country:US
Practice Address - Phone:914-699-7200
Practice Address - Fax:914-699-0837
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000368363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000368OtherN.Y.S. LICENSE NUMBER
NY000368OtherN.Y.S. LICENSE NUMBER