Healthcare Provider Details

I. General information

NPI: 1124558044
Provider Name (Legal Business Name): ALASKA PEDIATRIC NIGHT CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20209 EAGLE RIVER RD
EAGLE RIVER AK
99577-6800
US

IV. Provider business mailing address

20209 EAGLE RIVER RD
EAGLE RIVER AK
99577-6800
US

V. Phone/Fax

Practice location:
  • Phone: 907-201-7801
  • Fax:
Mailing address:
  • Phone: 907-201-7801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number113174
License Number StateAK

VIII. Authorized Official

Name: JENNIFER AUSTIN
Title or Position: CEO
Credential: CPNP
Phone: 907-201-7801