Provider Demographics
NPI:1225759798
Name:HOLLAND, TYRA R
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:R
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3339 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77703-3927
Mailing Address - Country:US
Mailing Address - Phone:281-678-2006
Mailing Address - Fax:
Practice Address - Street 1:3339 WEST AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77703-3927
Practice Address - Country:US
Practice Address - Phone:281-678-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX347C00000X347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX747156Medicaid