Healthcare Provider Details

I. General information

NPI: 1245541143
Provider Name (Legal Business Name): PETERS CREEK MEDICAL SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20905 EASTSIDE DR
CHUGIAK AK
99567-6286
US

IV. Provider business mailing address

20905 EASTSIDE DR
CHUGIAK AK
99567-6286
US

V. Phone/Fax

Practice location:
  • Phone: 907-688-0901
  • Fax: 907-688-0830
Mailing address:
  • Phone: 907-688-0901
  • Fax: 907-688-0830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAK4987
License Number StateAK

VIII. Authorized Official

Name: DR. OLGA IRIS WASILE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 907-688-0901