Provider Demographics
NPI:1962490177
Name:LOEBL, HOLLY ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:LOEBL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:HOLLY
Other - Middle Name:A
Other - Last Name:SUNDVALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:258 S CHICKASAW TRL STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-3501
Mailing Address - Country:US
Mailing Address - Phone:407-303-6865
Mailing Address - Fax:407-303-6537
Practice Address - Street 1:258 S CHICKASAW TRL STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3501
Practice Address - Country:US
Practice Address - Phone:407-303-6865
Practice Address - Fax:407-303-6537
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102707363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL391595OtherWELLCARE
FL292856600Medicaid
FLQ66717Medicare UPIN
FLU7168ZMedicare ID - Type Unspecified