=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124355359
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE UDELHOVEN PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2009
-----------------------------------------------------
Last Update Date | 02/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35670 KENAI SPUR HWY STE 103A
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-7649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-260-1655
-----------------------------------------------------
Fax | 980-495-8870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48690 TOTE RD
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-9155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PADA893
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------