MEDICARE: MRS. ROSE MARIE HOLODNIAK 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	363AM0700X	Medical Physician Assistant	PA9102591	FL

General Provider Information

NPI Number	:	1790858397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ROSE MARIE HOLODNIAK PA

Provider Business Mailing Address
First Line	:	1383 PROVIDENCE RD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-4885
Country	:	US
Telephone Number	:	813-681-5714
Fax Number	:	813-689-9557

Provider Business Practice Location Address
First Line	:	1383 PROVIDENCE RD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-4885
Country	:	US
Telephone Number	:	813-681-5714
Fax Number	:	813-689-9557

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	03/30/2011

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