Healthcare Provider Details

I. General information

NPI: 1528270014
Provider Name (Legal Business Name): LON PUTNAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHIEF EDDIE HOFFMAN HIGHWAY
BETHEL AK
99559-0287
US

IV. Provider business mailing address

P.O. BOX 287
BETHEL AK
99559-0287
US

V. Phone/Fax

Practice location:
  • Phone: 907-543-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number228
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: