Healthcare Provider Details

I. General information

NPI: 1831123165
Provider Name (Legal Business Name): WILLOW PHYSICAL THERAPY, LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 4TH AVE # 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 TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number183875
License Number StateAK

VIII. Authorized Official

Name: AISHA WILBUR
Title or Position: OWNER
Credential:
Phone: 907-456-5990