Healthcare Provider Details

I. General information

NPI: 1053574293
Provider Name (Legal Business Name): PTARMIGAN PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3543 E MERIDIAN PARK LOOP STE A
WASILLA AK
99654-7233
US

IV. Provider business mailing address

3543 E MERIDIAN PARK LOOP STE A
WASILLA AK
99654-7233
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-4543
  • Fax: 907-357-4533
Mailing address:
  • Phone: 907-357-4543
  • Fax: 907-357-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateAK

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. LAURA J PETERSON
Title or Position: OWNER
Credential: MD
Phone: 907-357-4543