Healthcare Provider Details

I. General information

NPI: 1497641153
Provider Name (Legal Business Name): DERMATOLOGY AND DERMATOPATHOLOGY OF ALASKA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 E 42ND AVE STE 301
ANCHORAGE AK
99508-5228
US

IV. Provider business mailing address

2401 E 42ND AVE STE 301
ANCHORAGE AK
99508-5228
US

V. Phone/Fax

Practice location:
  • Phone: 907-563-3204
  • Fax: 907-563-4283
Mailing address:
  • Phone: 907-563-3204
  • Fax: 907-563-4283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JAYNE S FORTSON
Title or Position: OWNER
Credential: M.D.
Phone: 907-563-3204