Healthcare Provider Details

I. General information

NPI: 1639491798
Provider Name (Legal Business Name): HOLLY MARIE MORALES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY MARIE SQUIBB PA-C

II. Dates (important events)

Enumeration Date: 02/17/2010
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WILLMAR AVE SW
WILLMAR MN
56201-3556
US

IV. Provider business mailing address

101 WILLMAR AVE SW
WILLMAR MN
56201-3556
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-5079
  • Fax: 320-231-5067
Mailing address:
  • Phone: 320-231-5079
  • Fax: 320-231-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10706
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: