Healthcare Provider Details

I. General information

NPI: 1932263043
Provider Name (Legal Business Name): MARTA G POORE ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 TONGASS AVE
KETCHIKAN AK
99901-5746
US

IV. Provider business mailing address

3100 TONGASS AVE
KETCHIKAN AK
99901-5746
US

V. Phone/Fax

Practice location:
  • Phone: 907-228-7688
  • Fax: 907-228-8468
Mailing address:
  • Phone: 907-228-7688
  • Fax: 907-228-8468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number82 AND 10053
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number82 AND 10053
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: