Healthcare Provider Details

I. General information

NPI: 1205958287
Provider Name (Legal Business Name): STATE OF ALASKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 PALMER WASILLA HWY SUITE 3
WASILLA AK
99654-7236
US

IV. Provider business mailing address

3223 PALMER WASILLA HWY SUITE 3
WASILLA AK
99654-7236
US

V. Phone/Fax

Practice location:
  • Phone: 907-352-6600
  • Fax: 907-376-3096
Mailing address:
  • Phone: 907-352-6600
  • Fax: 907-376-3096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberAK529
License Number StateAK

VII. Legacy identifiers

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

# 1
IdentifierNPO529PH0529
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: MS. VIOLA JEAN HAROSIA
Title or Position: NURSE PRACTIONER
Credential: CNM
Phone: 907-352-6650