=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487637674
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY D. HOLTZ PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 ROBBINS ST SUITE 7004
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-573-7307
-----------------------------------------------------
Fax | 203-573-6555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 JEREMY SWAMP RD
-----------------------------------------------------
City | SOUTHBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06488-2360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-267-5212
-----------------------------------------------------
Fax | 203-267-5212
-----------------------------------------------------
=====================================================
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 | 000716
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------