Provider Demographics
NPI:1902873748
Name:HOLLIS, MARK J (PA C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:HOLLIS
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:J
Other - Last Name:HOLLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:15 SANTA ROSA STREET
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1811
Mailing Address - Country:US
Mailing Address - Phone:805-541-2650
Mailing Address - Fax:805-541-4043
Practice Address - Street 1:15 SANTA ROSA STREET
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1811
Practice Address - Country:US
Practice Address - Phone:805-541-2650
Practice Address - Fax:805-541-4043
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA10498RMedicare ID - Type Unspecified
R92963Medicare UPIN