Healthcare Provider Details

I. General information

NPI: 1013276237
Provider Name (Legal Business Name): MAURA JANE HOLCOMB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 S MILLENIUM WAY STE 100
MERIDIAN ID
83642-6457
US

IV. Provider business mailing address

1618 S MILLENIUM WAY STE 100
MERIDIAN ID
83642-6457
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-3376
  • Fax: 208-884-0858
Mailing address:
  • Phone: 208-884-3376
  • Fax: 208-884-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number70591
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10044142
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM16146
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: