Provider Demographics
NPI:1871586784
Name:HOLLIS, DEBORAH SUSAN (PA-C)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:SUSAN
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:S
Other - Last Name:BARRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1455 E BERT KOUNS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4623
Mailing Address - Fax:318-798-4591
Practice Address - Street 1:1455 E BERT KOUNS LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4623
Practice Address - Fax:318-798-4591
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10355.RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00090026OtherRAILROAD MEDICARE NUMBER
LA1625221Medicaid
LA56742PB65Medicare PIN
LA1625221Medicaid
LA56742P412Medicare PIN