Provider Demographics
NPI:1427297332
Name:HOLLOWAY, KENNETH RAY (PA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAY
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 S HOLT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-4804
Mailing Address - Country:US
Mailing Address - Phone:317-247-3300
Mailing Address - Fax:
Practice Address - Street 1:2002 S HOLT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-4804
Practice Address - Country:US
Practice Address - Phone:317-247-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001067A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant