Healthcare Provider Details

I. General information

NPI: 1962804518
Provider Name (Legal Business Name): PPGNW - ALASKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 LAKE OTIS PKWY SUITE 205
ANCHORAGE AK
99508-5223
US

IV. Provider business mailing address

2001 E MADISON ST
SEATTLE WA
98122-2959
US

V. Phone/Fax

Practice location:
  • Phone: 800-769-0045
  • Fax:
Mailing address:
  • Phone: 800-769-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD4865
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD5285
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberANP970
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberANP1382
License Number StateAK
# 5
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberANP915
License Number StateAK

VIII. Authorized Official

Name: MARY WENDT
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 206-328-6826