Healthcare Provider Details

I. General information

NPI: 1184001042
Provider Name (Legal Business Name): JONATHAN DAWSON HEDGES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 DIPLOMACY DR
ANCHORAGE AK
99508-5919
US

IV. Provider business mailing address

4501 DIPLOMACY DR
ANCHORAGE AK
99508-5919
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-4955
  • Fax:
Mailing address:
  • Phone: 907-729-4955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10094291-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number197005
License Number StateAK

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: