Provider Demographics
NPI:1699755231
Name:HOLLAND, JACK (CRNA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:HOLLAND
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 1:6127 KINGSFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-6317
Mailing Address - Country:US
Mailing Address - Phone:307-203-7739
Mailing Address - Fax:
Practice Address - Street 1:HEBER VALLEY HOSPITAL
Practice Address - Street 2:1485 US-40
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032
Practice Address - Country:US
Practice Address - Phone:435-654-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC161328163W00000X
NV821399367500000X
NC053081367500000X
UT9809402-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051521Medicaid
NC8051521Medicaid