Healthcare Provider Details

I. General information

NPI: 1619113123
Provider Name (Legal Business Name): AISHA CORREA WILBUR D.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 4TH AVE STE 102
FAIRBANKS AK
99701-4714
US

IV. Provider business mailing address

544 4TH AVE STE 102
FAIRBANKS AK
99701-4714
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-5990
  • Fax: 907-374-8023
Mailing address:
  • Phone: 907-456-5990
  • Fax: 907-374-8023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2108
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number8225
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2108
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: