1790763233 NPI number — MR. MARK R HOLMBERG C.R.N.A.

Table of content: MR. MARK R HOLMBERG C.R.N.A. (NPI 1790763233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790763233 NPI number — MR. MARK R HOLMBERG C.R.N.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLMBERG
Provider First Name:
MARK
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
C.R.N.A.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790763233
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2415 WESTERN AVE
Provider Second Line Business Mailing Address:
APT 503
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98121-1394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-741-5259
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 9TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98101-2756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-223-6980
Provider Business Practice Location Address Fax Number:
206-223-6982
Provider Enumeration Date:
01/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R 154503-0 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP30007744 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5069HO . This is a "BLUE SHIELD #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: RNA0011 . This is a "ALASKA DSHS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00444040 . This is a "RAILROAD MC #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9653981 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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