Healthcare Provider Details

I. General information

NPI: 1528044955
Provider Name (Legal Business Name): DAVID G HOLLAND NPC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SCH 100
REXBURG ID
83460-2010
US

IV. Provider business mailing address

1025 IONA ST
IDAHO FALLS ID
83402-1915
US

V. Phone/Fax

Practice location:
  • Phone: 208-456-1300
  • Fax: 208-456-1306
Mailing address:
  • Phone: 208-525-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP254A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: