Basic Information
| Provider Information | |||||||||
| NPI: | 1336460922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | SAMPLES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAMPLES | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1450 MATTHEWS TOWNSHIP PKWY | ||||||||
| Address2: | STE 250 | ||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281055331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199664653 | ||||||||
| FaxNumber: | 9199667841 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 MATTHEWS TOWNSHIP PKWY STE 250 | ||||||||
| Address2: | |||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199664653 | ||||||||
| FaxNumber: | 9199667841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2018-01719 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1336460922 | 05 | NC | MEDICAID |