Healthcare Provider Details

I. General information

NPI: 1932744836
Provider Name (Legal Business Name): ALTAIR INTEGRATIVE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 E USA CIR STE 108
WASILLA AK
99654-7106
US

IV. Provider business mailing address

892 E USA CIR STE 108
WASILLA AK
99654-7106
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-1818
  • Fax: 907-357-1814
Mailing address:
  • Phone: 907-357-1818
  • Fax: 907-357-1814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1702799
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
Identifier1636141
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 3
Identifier1633093
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: DR. TARA E WORKMAN DC
Title or Position: CEO
Credential: DC
Phone: 907-357-1818