=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467724401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. JADYN HOLSTE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2012
-----------------------------------------------------
Last Update Date | 07/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2570 HAYMAKER RD
-----------------------------------------------------
City | MONROEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15146-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-858-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1604 PITTSBURGH AVE
-----------------------------------------------------
City | MT LAKE PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21550-3418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-243-3433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | C04684
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | MA057591
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------