Provider Demographics
NPI:1932130226
Name:HOLLAR, TAMA JORDAN (CRNA)
Entity Type:Individual
Prefix:
First Name:TAMA
Middle Name:JORDAN
Last Name:HOLLAR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TAMA
Other - Middle Name:D
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:10919 64TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-8522
Mailing Address - Country:US
Mailing Address - Phone:253-858-7129
Mailing Address - Fax:
Practice Address - Street 1:3209 S 23RD ST
Practice Address - Street 2:STE 340
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1602
Practice Address - Country:US
Practice Address - Phone:253-272-5127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-066746367500000X
FLARNP2698912367500000X
WAAP60311608367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306476000Medicaid
WAG8915279OtherMDCR PTAN (K)
FLG2338OtherBCBS
WAG8915280OtherMDCR PTAN (P)