Provider Demographics
NPI:1306063912
Name:FERGUSON, HOLLY MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:MARIE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:HOLLY
Other - Middle Name:MARIE
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:6944 E BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-1916
Mailing Address - Country:US
Mailing Address - Phone:480-436-5194
Mailing Address - Fax:480-436-5193
Practice Address - Street 1:6944 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-1916
Practice Address - Country:US
Practice Address - Phone:480-436-5194
Practice Address - Fax:480-436-5193
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9278363AM0700X
UT97043118906363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR40276Medicare UPIN