Basic Information
| Provider Information | |||||||||
| NPI: | 1417973066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLORAN | ||||||||
| FirstName: | KRYSTINA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANGEL | ||||||||
| OtherFirstName: | KRYSTINA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1250 S CLEARVIEW AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852093378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809889108 | ||||||||
| FaxNumber: | 4808134460 | ||||||||
| Practice Location | |||||||||
| Address1: | 3160 E QUEEN CREEK RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852978402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808891157 | ||||||||
| FaxNumber: | 4808891160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 01/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3459 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 125538 | 05 | AZ | MEDICAID |