Healthcare Provider Details

I. General information

NPI: 1588651053
Provider Name (Legal Business Name): THOMAS MANFORD DALE III PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST
FAIRBANKS AK
99701-5925
US

IV. Provider business mailing address

607 OLD STEESE HWY SUITE B PMB255
FAIRBANKS AK
99701-3131
US

V. Phone/Fax

Practice location:
  • Phone: 907-458-5555
  • Fax:
Mailing address:
  • Phone: 907-388-0748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number475
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: