Provider Demographics
NPI:1528044955
Name:HOLLAND, DAVID G (NPC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:G
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 IONA ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-1915
Mailing Address - Country:US
Mailing Address - Phone:208-525-8102
Mailing Address - Fax:
Practice Address - Street 1:SCH 100
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83460-2010
Practice Address - Country:US
Practice Address - Phone:208-456-1300
Practice Address - Fax:208-456-1306
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP254A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner