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General NPI Number Information
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NPI Number | 1578110011
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Entity Type | Organization
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Legal Business Name | WASILLA INTERNAL MEDICINE LLC
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Dates
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Enumeration Date | 08/20/2019
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Last Update Date | 08/20/2019
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Provider Practice Location Address
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Address Line | 3719 E MERIDIAN LOOP STE F
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City | WASILLA
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State | AK
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Zip | 99654-7273
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Country | US
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Telephone | 907-373-5940
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Fax | 907-373-5947
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Provider Business Mailing Address
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Address Line | 3719 E MERIDIAN LOOP STE F
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City | WASILLA
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State | AK
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Zip | 99654-7273
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Country | US
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Telephone | 907-373-5940
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Fax | 907-373-5947
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | METTESSA MAYE REID
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Credential |
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Telephone | 907-250-3482
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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