Basic Information
| Provider Information | |||||||||
| NPI: | 1932211729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLOWAY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 540 JETTS DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066666000 | ||||||||
| FaxNumber: | 6066666102 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 JETTS DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066666000 | ||||||||
| FaxNumber: | 6066666102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1109901 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100021760 | 05 | KY | MEDICAID | 000000492112 | 01 | KY | BCBS | OTHER |