Healthcare Provider Details

I. General information

NPI: 1689740508
Provider Name (Legal Business Name): TONJA LYNN HOTRUM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 HUFFMAN PARK DR UNIT 210
ANCHORAGE AK
99515-3534
US

IV. Provider business mailing address

1389 HUFFMAN PARK DR UNIT 210
ANCHORAGE AK
99515-3534
US

V. Phone/Fax

Practice location:
  • Phone: 907-250-0571
  • Fax: 907-600-5083
Mailing address:
  • Phone: 907-250-0571
  • Fax: 907-600-5083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1816
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number752
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: