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NPI Code Detail

MEDICARE: IVY WEAKLAND PA-C

MEDICARE: IVY WEAKLAND PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
2363AM0700XMedical Physician Assistant115459AK

General Provider Information

NPI Number : 1902263387
Entity Type Code : Individual
Provider Name (Legal Business Name) : IVY WEAKLAND PA-C
Provider Business Mailing Address
First Line : 9500 INDEPENDENCE DR
Second Line : STE 900
City : ANCHORAGE
State : AK
Zip : 99507-4686
Country : US
Telephone Number : 907-522-1341
Fax Number : 907-522-1343
Provider Business Practice Location Address
First Line : 4311 11TH AVE NE STE 200
Second Line :
City : SEATTLE
State : WA
Zip : 98105-6367
Country : US
Telephone Number : 206-616-4001
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/15/2016
Last Update Date : 11/29/2016

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Directions to “ IVY WEAKLAND PA-C” Practice Location

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