Provider Demographics
NPI:1811928625
Name:LIBERATORE, HOLLY C (MD)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:C
Last Name:LIBERATORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:MOSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 11510
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-414-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23705207Q00000X
WAMD00042244207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05483727Medicaid
WA8351926Medicaid
H74702Medicare UPIN