Provider Demographics
NPI:1053402057
Name:HOLTCAMP, MARK E (PA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:HOLTCAMP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9139
Mailing Address - Country:US
Mailing Address - Phone:440-975-5575
Mailing Address - Fax:440-944-0920
Practice Address - Street 1:2785 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9139
Practice Address - Country:US
Practice Address - Phone:440-975-5575
Practice Address - Fax:440-944-0920
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000204363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHHOPA19557Medicare ID - Type Unspecified
OHP67428Medicare UPIN