Provider Demographics
NPI:1285296913
Name:HOLTHAUS, MARY (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HOLTHAUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 DEFENSE HWY STE 210
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7071
Mailing Address - Country:US
Mailing Address - Phone:240-205-5832
Mailing Address - Fax:
Practice Address - Street 1:122 DEFENSE HWY STE 210
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7071
Practice Address - Country:US
Practice Address - Phone:410-266-9694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDC07349363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC07349OtherMARYLAND BOARD OF PHYSICIANS