Healthcare Provider Details

I. General information

NPI: 1235587544
Provider Name (Legal Business Name): JOHN ELMER MCCRARY COMMUNITY HEALTHAIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 5TH TED STEVENS WAY MANIILAQ HEALTH CENTER
KOTZEBUE AK
99752-0043
US

IV. Provider business mailing address

PO BOX 43 MANIILAQ ASSOCIATION
KOTZEBUE AK
99752-0043
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-3321
  • Fax:
Mailing address:
  • Phone: 907-442-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: