Provider Demographics
NPI:1124066642
Name:HOLOBOWICZ, BENJAMIN JR (PAC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:HOLOBOWICZ
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 JOHN STARK HWY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NH
Mailing Address - Zip Code:03773-1807
Mailing Address - Country:US
Mailing Address - Phone:603-863-4100
Mailing Address - Fax:603-863-3585
Practice Address - Street 1:11 JOHN STARK HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NH
Practice Address - Zip Code:03773
Practice Address - Country:US
Practice Address - Phone:603-863-4100
Practice Address - Fax:603-863-3585
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030828363A00000X
NH0433P363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTQ57013Medicare UPIN
NHQ57013Medicare UPIN
VT000191Medicare PIN