Provider Demographics
NPI:1790763233
Name:HOLMBERG, MARK R (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:HOLMBERG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 WESTERN AVE
Mailing Address - Street 2:APT 503
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1394
Mailing Address - Country:US
Mailing Address - Phone:612-741-5259
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6980
Practice Address - Fax:206-223-6982
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 154503-0367500000X
WAAP30007744367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5069HOOtherBLUE SHIELD #
WARNA0011OtherALASKA DSHS
WAP00444040OtherRAILROAD MC #
WA9653981Medicaid
WARNA0011OtherALASKA DSHS