Provider Demographics
NPI:1760351415
Name:MANSOUR, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:MANSOUR
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 1:12060 THISTLE BRAES TER
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-4929
Mailing Address - Country:US
Mailing Address - Phone:619-672-9346
Mailing Address - Fax:
Practice Address - Street 1:12060 THISTLE BRAES TER
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-4929
Practice Address - Country:US
Practice Address - Phone:619-672-9346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-31
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant