Healthcare Provider Details

I. General information

NPI: 1346080892
Provider Name (Legal Business Name): AVERY LEVONUK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11421 OLD GLENN HWY
EAGLE RIVER AK
99577-7783
US

IV. Provider business mailing address

11421 OLD GLENN HWY
EAGLE RIVER AK
99577-7783
US

V. Phone/Fax

Practice location:
  • Phone: 907-622-2500
  • Fax:
Mailing address:
  • Phone: 907-622-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number2500321
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number202644
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: