Healthcare Provider Details

I. General information

NPI: 1700020005
Provider Name (Legal Business Name): ANDY WADE HOLLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 ALCORN DR STE 102
CORINTH MS
38834-9302
US

IV. Provider business mailing address

1710 FIELDSTONE FARMS RD
CORINTH MS
38834-7561
US

V. Phone/Fax

Practice location:
  • Phone: 662-286-2522
  • Fax:
Mailing address:
  • Phone: 662-678-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5474
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number23290
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: