Provider Demographics
NPI:1912089947
Name:TSE, HOLLY ILENA FABER (MD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ILENA FABER
Last Name:TSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 NE 134TH STREET, STE 200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686
Mailing Address - Country:US
Mailing Address - Phone:360-566-9355
Mailing Address - Fax:360-816-1327
Practice Address - Street 1:900 NE 139TH ST
Practice Address - Street 2:STE 202
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2513
Practice Address - Country:US
Practice Address - Phone:360-566-9355
Practice Address - Fax:360-816-1327
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26913207R00000X, 208000000X
WAMD60266119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241816Medicaid
OR241816Medicaid
ORR142035Medicare PIN