Healthcare Provider Details

I. General information

NPI: 1639241110
Provider Name (Legal Business Name): FREDERICK SAMUEL GREENE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 POLIVENIA TPKE
SAINT PAUL ISLAND AK
99660
US

IV. Provider business mailing address

PO BOX 148
ST PAUL AK
99660-0148
US

V. Phone/Fax

Practice location:
  • Phone: 907-546-8300
  • Fax:
Mailing address:
  • Phone: 907-546-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAK212
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: