Healthcare Provider Details

I. General information

NPI: 1396140950
Provider Name (Legal Business Name): ALASKA PEDIATRIC SPECIALTIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 01/05/2024
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE OTIS PKWY SUITE 206
ANCHORAGE AK
99508-5229
US

IV. Provider business mailing address

4100 LAKE OTIS PKWY SUITE 206
ANCHORAGE AK
99508-5229
US

V. Phone/Fax

Practice location:
  • Phone: 907-929-7337
  • Fax: 907-929-7330
Mailing address:
  • Phone: 907-929-7337
  • Fax: 907-929-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY BRENT ROATEN
Title or Position: PRESIDENT
Credential: MD
Phone: 907-717-9871