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General NPI Number Information
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NPI Number | 1912010687
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Entity Type | Organization
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Legal Business Name | MAT-SU EAR, NOSE, THROAT & FACIAL PLASTICS, INC.
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Dates
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Enumeration Date | 08/16/2006
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Last Update Date | 12/27/2017
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Provider Practice Location Address
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Address Line | 2490 SOUTH WOODWORTH LOOP 201
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City | PALMER
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State | AK
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Zip | 99645
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Country | US
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Telephone | 907-745-9200
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Fax | 907-745-9201
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Provider Business Mailing Address
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Address Line | 2490 SOUTH WOODWORTH LOOP 201
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City | PALMER
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State | AK
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Zip | 99645
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Country | US
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Telephone | 907-745-9200
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Fax | 907-745-9201
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANDREW RICHARD PULLIAM
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Credential | MD
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Telephone | 907-745-9200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 4516
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License Number State | AK
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