Provider Demographics
NPI:1871741785
Name:HOLMBERG, THARON B (CRNP)
Entity type:Individual
Prefix:MR
First Name:THARON
Middle Name:B
Last Name:HOLMBERG
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 PENN PLZ
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10119-0002
Mailing Address - Country:US
Mailing Address - Phone:570-452-2138
Mailing Address - Fax:
Practice Address - Street 1:701 SENECA ST STE 646C
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-1372
Practice Address - Country:US
Practice Address - Phone:716-995-4450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009917363L00000X
NY307563363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner