Healthcare Provider Details

I. General information

NPI: 1376163592
Provider Name (Legal Business Name): HOLLY A WATSON MMS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MIRANOVA PL STE 500
COLUMBUS OH
43215-7052
US

IV. Provider business mailing address

2 MIRANOVA PL STE 500
COLUMBUS OH
43215-7052
US

V. Phone/Fax

Practice location:
  • Phone: 614-321-9743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003219A
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003219A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: