Healthcare Provider Details

I. General information

NPI: 1790763233
Provider Name (Legal Business Name): MARK R HOLMBERG C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 9TH AVE
SEATTLE WA
98101-2756
US

IV. Provider business mailing address

2415 WESTERN AVE APT 503
SEATTLE WA
98121-1394
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-6980
  • Fax: 206-223-6982
Mailing address:
  • Phone: 612-741-5259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 154503-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30007744
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: