MEDICARE: SAMUEL KYLE HOLLOWAY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110005806	VA

General Provider Information

NPI Number	:	1023546256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL KYLE HOLLOWAY PA

Provider Business Mailing Address
First Line	:	1944 CENTERVILLE TPKE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6839
Country	:	US
Telephone Number	:	757-362-9067
Fax Number	:

Provider Business Practice Location Address
First Line	:	1944 CENTERVILLE TPKE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6839
Country	:	US
Telephone Number	:	757-362-9067
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2017
Last Update Date	:	12/27/2024

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