Provider Demographics
NPI:1417973066
Name:HOLLORAN, KRYSTINA MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:MICHELLE
Last Name:HOLLORAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRYSTINA
Other - Middle Name:MICHELLE
Other - Last Name:DANGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1250 S CLEARVIEW AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3378
Mailing Address - Country:US
Mailing Address - Phone:480-988-9108
Mailing Address - Fax:480-813-4460
Practice Address - Street 1:3160 E QUEEN CREEK RD
Practice Address - Street 2:SUITE 104
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-8402
Practice Address - Country:US
Practice Address - Phone:480-889-1157
Practice Address - Fax:480-889-1160
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ125538Medicaid
AZZ110962Medicare PIN
AZZ110961Medicare PIN
Q71410Medicare UPIN