Provider Demographics
NPI:1053422154
Name:HOLLAND, RANDY (PA-C)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1231
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-1231
Mailing Address - Country:US
Mailing Address - Phone:406-265-2211
Mailing Address - Fax:
Practice Address - Street 1:20 13TH ST W
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-5215
Practice Address - Country:US
Practice Address - Phone:406-265-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT191363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTS68511Medicare UPIN
MT1153260004Medicare PIN