Healthcare Provider Details

I. General information

NPI: 1699737692
Provider Name (Legal Business Name): KERRY DEAN VANCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 04/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S WOODWORTH LOOP
PALMER AK
99645-8984
US

IV. Provider business mailing address

4300 B ST STE 200
ANCHORAGE AK
99503-5933
US

V. Phone/Fax

Practice location:
  • Phone: 907-375-3355
  • Fax: 907-375-3351
Mailing address:
  • Phone: 907-375-3355
  • Fax: 907-375-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH5367
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2012025753
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7596
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: