1932130226 NPI number — TAMA JORDAN HOLLAR CRNA

Table of content: TAMA JORDAN HOLLAR CRNA (NPI 1932130226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932130226 NPI number — TAMA JORDAN HOLLAR CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLAR
Provider First Name:
TAMA
Provider Middle Name:
JORDAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FULTON
Provider Other First Name:
TAMA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932130226
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10919 64TH AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GIG HARBOR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98332-8522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-858-7129
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3209 S 23RD ST
Provider Second Line Business Practice Location Address:
STE 340
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-1602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-272-5127
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2006

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:  1-066746 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: ARNP2698912 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP60311608 , 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: 306476000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: G8915279 . This is a "MDCR PTAN (K)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G2338 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: G8915280 . This is a "MDCR PTAN (P)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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