Healthcare Provider Details

I. General information

NPI: 1275924300
Provider Name (Legal Business Name): HAL BRET WILLARDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 S WOODWORTH LOOP STE 101
PALMER AK
99645-7457
US

IV. Provider business mailing address

1398 N RIVER ROCK CIR
PALMER AK
99645
US

V. Phone/Fax

Practice location:
  • Phone: 907-745-7546
  • Fax: 907-745-7540
Mailing address:
  • Phone: 907-360-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number183209
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: