Healthcare Provider Details

I. General information

NPI: 1356433932
Provider Name (Legal Business Name): RANDALL M HOLLAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MARTIN LUTHER KING JR WAY
TACOMA WA
98405
US

IV. Provider business mailing address

PO BOX 5299
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-4613
  • Fax:
Mailing address:
  • Phone: 253-403-4613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00031380
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: