Basic Information
| Provider Information | |||||||||
| NPI: | 1962434399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLOWAY | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5424 GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278451736 | ||||||||
| FaxNumber: | 7278490759 | ||||||||
| Practice Location | |||||||||
| Address1: | 21298 OLEAN BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416291181 | ||||||||
| FaxNumber: | 9416246020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN3180702 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 310998400 | 05 | FL | MEDICAID |