Healthcare Provider Details

I. General information

NPI: 1528503687
Provider Name (Legal Business Name): NORTHWOODS FAMILY MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E. PALMER-WASILLA HWY, #400
WASILLA AK
99654
US

IV. Provider business mailing address

PO BOX 876628
WASILLA AK
99687-6628
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-9400
  • Fax:
Mailing address:
  • Phone: 907-357-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4823
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number340
License Number StateAK

VIII. Authorized Official

Name: MR. MYLES STANDISH JR.
Title or Position: REPRESENTATIVE/AGENT
Credential:
Phone: 206-300-3992