Healthcare Provider Details

I. General information

NPI: 1013551456
Provider Name (Legal Business Name): MEDICAL NETWORK OF ALASKA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10543 KENAI SPUR HWY
KENAI AK
99611-7812
US

IV. Provider business mailing address

3122 E MERIDIAN PARK LOOP
WASILLA AK
99654-7255
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-9590
  • Fax: 907-357-9593
Mailing address:
  • Phone: 907-357-9590
  • Fax: 907-357-9593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JACQUELYN RENEE BLOMKER
Title or Position: RCM
Credential:
Phone: 907-864-4625