Provider Demographics
NPI:1710797980
Name:HOLSONBACK, MIRANDA LEA (CRNA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEA
Last Name:HOLSONBACK
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 N STATE HIGHWAY 161 STE 200
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2241
Mailing Address - Country:US
Mailing Address - Phone:214-687-0001
Mailing Address - Fax:
Practice Address - Street 1:6225 N STATE HIGHWAY 161 STE 200
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2241
Practice Address - Country:US
Practice Address - Phone:214-687-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1020393163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse