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General NPI Number Information
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NPI Number | 1790184646
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Entity Type | Organization
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Legal Business Name | ARCTIC PHYSICAL MEDICINE WASILLA
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Dates
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Enumeration Date | 08/16/2014
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Last Update Date | 08/16/2014
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Provider Practice Location Address
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Address Line | 1830 E PARKS HWY STE A120
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City | WASILLA
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State | AK
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Zip | 99654-7380
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Country | US
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Telephone | 206-713-4721
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Fax |
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Provider Business Mailing Address
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Address Line | 1830 E PARKS HWY STE A120
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City | WASILLA
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State | AK
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Zip | 99654-7380
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KYLE T BERGQUIST
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Credential |
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Telephone | 206-713-4721
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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 | 1305
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License Number State | AK
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