Provider Demographics
NPI:1124486782
Name:THOMAS, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:EVMS MEDICAL GROUP
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:SUITE 572
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA110005213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1124486782OtherOPTIMA HEALTH
VA1124486782OtherCORVEL
VA1124486782Medicaid
VA1124486782OtherTRICARE/CHAMPUS
VA1124486782OtherMULTIPLAN
VA1124486782OtherUSA MANAGED CARE
VA1124486782OtherHUMANA
NC1124486782Medicaid
VA1124486782Medicaid