Provider Demographics
NPI:1366273682
Name:HOLLENBACK, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:HOLLENBACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-0391
Mailing Address - Country:US
Mailing Address - Phone:480-216-0410
Mailing Address - Fax:
Practice Address - Street 1:1515 E RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6507
Practice Address - Country:US
Practice Address - Phone:480-216-0410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ-4388363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical