Provider Demographics
NPI:1720187719
Name:HOLBACH, MARY K (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:HOLBACH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:MODER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8681 EAGLE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8628
Mailing Address - Country:US
Mailing Address - Phone:651-251-8021
Mailing Address - Fax:651-251-8050
Practice Address - Street 1:8681 EAGLE POINT BLVD
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8628
Practice Address - Country:US
Practice Address - Phone:651-251-8021
Practice Address - Fax:651-251-8050
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0944360367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN861343500Medicaid
MN430003883Medicare ID - Type Unspecified