Provider Demographics
NPI:1942754635
Name:HOLLOWAY, RICHARD DAWSON III (FNP-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAWSON
Last Name:HOLLOWAY
Suffix:III
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:RICKY
Other - Middle Name:
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1068 CRESTHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1068 CRESTHAVEN RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0800
Practice Address - Country:US
Practice Address - Phone:901-866-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000020944363L00000X
MS901463363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ025239Medicaid
MO200040282Medicaid
AR220036758Medicaid
GA003182720AMedicaid
MS01585873Medicaid