Healthcare Provider Details

I. General information

NPI: 1619708005
Provider Name (Legal Business Name): SHAWN HOLLOWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 CLARIDON AVE
MARION OH
43302-5603
US

IV. Provider business mailing address

475 CLARIDON AVE
MARION OH
43302-5603
US

V. Phone/Fax

Practice location:
  • Phone: 740-360-8171
  • Fax:
Mailing address:
  • Phone: 740-360-8171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberRP037648
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: