Provider Demographics
NPI:1528110061
Name:HOLLEY, DESIREE (PA-C)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:HOLLEY
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 1:390 SABINE STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:HEMPHILL
Mailing Address - State:TX
Mailing Address - Zip Code:75948-7065
Mailing Address - Country:US
Mailing Address - Phone:409-787-0006
Mailing Address - Fax:409-787-0008
Practice Address - Street 1:390 SABINE STREET
Practice Address - Street 2:SUITE D
Practice Address - City:HEMPHILL
Practice Address - State:TX
Practice Address - Zip Code:75948-7065
Practice Address - Country:US
Practice Address - Phone:409-787-0006
Practice Address - Fax:409-787-0008
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX335469802Medicaid
8283NDOtherBCBS
TX8285NDOtherBCBS
TX75-1976930-005OtherTRICARE
TX75-2616977-002OtherTRICARE
TX335469801Medicaid
TX75-0818167-015OtherTRICARE
TX75-0818167-022OtherTRICARE
TX75-2616977-001OtherTRICARE
TX75-0818167-044OtherTRICARE
TX335469803Medicaid
TX75-0818167-048OtherTRICARE
TX8286NDOtherBCBS
TX75-2616977-028OtherTRICARE
TX335469804Medicaid
TX8812NFOtherBCBS
TXP01290918OtherRAIL ROAD
TX324788YMAFMedicare PIN
TX8812NFOtherBCBS
8283NDOtherBCBS
TX75-0818167-048OtherTRICARE
TX335469803Medicaid
TXP01291370Medicare Oscar/Certification