Provider Demographics
NPI:1619708005
Name:HOLLOWAY, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 CLARIDON AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-5603
Mailing Address - Country:US
Mailing Address - Phone:740-360-8171
Mailing Address - Fax:
Practice Address - Street 1:475 CLARIDON AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-5603
Practice Address - Country:US
Practice Address - Phone:740-360-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRP037648172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty