Healthcare Provider Details

I. General information

NPI: 1083640387
Provider Name (Legal Business Name): MICHAEL THOMAS VON AH WHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9761 W MARGIN WAY
WASILLA AK
99623
US

IV. Provider business mailing address

1125 N COLONIAL DR
WASILLA AK
99654-6760
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-5400
  • Fax: 907-373-5740
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number879
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: