Provider Demographics
NPI:1902052699
Name:WANDELL, HOLLY A (PA-C)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:WANDELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 ROUTE 154
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:PA
Mailing Address - Zip Code:17724-7344
Mailing Address - Country:US
Mailing Address - Phone:570-506-3905
Mailing Address - Fax:
Practice Address - Street 1:175 LAMOKA RD
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-9429
Practice Address - Country:US
Practice Address - Phone:570-964-8001
Practice Address - Fax:570-890-2818
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant