Healthcare Provider Details

I. General information

NPI: 1427167113
Provider Name (Legal Business Name): KAREN DYAN IMPSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3719 E MERIDIAN LOOP SUITE D
WASILLA AK
99654-7270
US

IV. Provider business mailing address

3719 E MERIDIAN LOOP SUITE D
WASILLA AK
99654-7270
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-7337
  • Fax: 907-357-9029
Mailing address:
  • Phone: 907-373-7337
  • Fax: 907-357-9029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4300
License Number StateAK

VII. Legacy identifiers

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

# 1
IdentifierMD10661
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: