Healthcare Provider Details

I. General information

NPI: 1194114678
Provider Name (Legal Business Name): NICHOLAS ERNIE DAN WAGHIYI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AIRPORT RD 151
SAVOONGA AK
99769
US

IV. Provider business mailing address

AIRPORT RD 151
SAVOONGA AK
99769
US

V. Phone/Fax

Practice location:
  • Phone: 907-984-6513
  • Fax: 907-984-6068
Mailing address:
  • Phone: 907-984-6513
  • Fax: 907-984-6068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCHA II
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerCHA II

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: