Healthcare Provider Details

I. General information

NPI: 1134160120
Provider Name (Legal Business Name): ANDREW RICHARD PULLIAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 S WOODWORTH LOOP SUITE 201
PALMER AK
99645-7405
US

IV. Provider business mailing address

2490 S WOODWORTH LOOP SUITE 201
PALMER AK
99645-7405
US

V. Phone/Fax

Practice location:
  • Phone: 907-745-9200
  • Fax: 907-745-9201
Mailing address:
  • Phone: 907-745-9200
  • Fax: 907-745-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number4516
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: