Provider Demographics
NPI:1962150946
Name:ROBERTS, HOLLY R (PA-C)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:R
Other - Last Name:BEARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:12500 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1227
Mailing Address - Country:US
Mailing Address - Phone:262-857-5000
Mailing Address - Fax:262-857-5001
Practice Address - Street 1:12500 AURORA DR
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1227
Practice Address - Country:US
Practice Address - Phone:262-857-5000
Practice Address - Fax:262-857-5001
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5760-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100197616Medicaid