Healthcare Provider Details

I. General information

NPI: 1578475703
Provider Name (Legal Business Name): AUSTIN PICCOLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 CHIEF EDDIE HOFFMAN HWY
BETHEL AK
99559
US

IV. Provider business mailing address

528 CHIEF EDDIE HOFFMAN HWY
BETHEL AK
99559
US

V. Phone/Fax

Practice location:
  • Phone: 907-543-6000
  • Fax:
Mailing address:
  • Phone: 423-463-7865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number260629
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: