Basic Information
| Provider Information | |||||||||
| NPI: | 1881851632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLAND | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| OtherLastName: | HOLLAND | ||||||||
| OtherFirstName: | BRYCE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 173862 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802173862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E HAMPDEN AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037885000 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 363A00000X | PA.0004110 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 26977834 | 05 | CO | MEDICAID |