MEDICARE: DRUE HOLLOWAY HYDE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	9112515	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639714835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DRUE HOLLOWAY HYDE PA

Provider Business Mailing Address
First Line	:	7900 PASADENA BLVD APT 205
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-3581
Country	:	US
Telephone Number	:	303-324-7578
Fax Number	:

Provider Business Practice Location Address
First Line	:	1516 E LAS OLAS BLVD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2399
Country	:	US
Telephone Number	:	954-764-8900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2019
Last Update Date	:	11/12/2019

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Directions to “ DRUE HOLLOWAY HYDE PA” Practice Location

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