Healthcare Provider Details

I. General information

NPI: 1861415622
Provider Name (Legal Business Name): SHAN JIANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST
FAIRBANKS AK
99701-5925
US

IV. Provider business mailing address

3030 DAVIS RD APT C7
FAIRBANKS AK
99709-5270
US

V. Phone/Fax

Practice location:
  • Phone: 800-945-9877
  • Fax: 801-733-5618
Mailing address:
  • Phone: 907-460-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5387
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: