Healthcare Provider Details

I. General information

NPI: 1154192755
Provider Name (Legal Business Name): EMILY HOLMES-HACKERD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 DOMAIN DR APT 1024
MORGANTOWN WV
26501-2528
US

IV. Provider business mailing address

5000 DOMAIN DR APT 1024
MORGANTOWN WV
26501-2528
US

V. Phone/Fax

Practice location:
  • Phone: 215-859-2881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3223
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: