Healthcare Provider Details

I. General information

NPI: 1417316696
Provider Name (Legal Business Name): HOLLIS TAGGART STAHL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 GROSSMONT CENTER DR
LA MESA CA
91942-3009
US

IV. Provider business mailing address

5651 COPLEY DR
SAN DIEGO CA
92111-7903
US

V. Phone/Fax

Practice location:
  • Phone: 619-644-6705
  • Fax:
Mailing address:
  • Phone: 858-262-6344
  • Fax: 858-626-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: