Provider Demographics
NPI:1245840131
Name:HOLLISTER, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:HOLLISTER
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 1:245 AVERY LN
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13441-4237
Mailing Address - Country:US
Mailing Address - Phone:315-337-1200
Mailing Address - Fax:
Practice Address - Street 1:5 MASONIC AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316-1234
Practice Address - Country:US
Practice Address - Phone:315-245-3192
Practice Address - Fax:315-245-3195
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2025-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF346300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily