Healthcare Provider Details

I. General information

NPI: 1770375883
Provider Name (Legal Business Name): ISAAC MICHAEL HURST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 LATHROP ST
FAIRBANKS AK
99701-7426
US

IV. Provider business mailing address

211 CLARKSON DR APT 71
FAIRBANKS AK
99709-3117
US

V. Phone/Fax

Practice location:
  • Phone: 936-397-9445
  • Fax:
Mailing address:
  • Phone: 936-397-9445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: