MEDICARE: JONATHAN MARK VANRAVENSWAAY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A133945	CA
2	207Q00000X	Family Medicine Physician	111160	AK

General Provider Information

NPI Number	:	1154768588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN MARK VANRAVENSWAAY MD

Provider Business Mailing Address
First Line	:	PO BOX 140968
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99514-0968
Country	:	US
Telephone Number	:	805-766-1049
Fax Number	:

Provider Business Practice Location Address
First Line	:	3521 MOUNTAIN VIEW DR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-1111
Country	:	US
Telephone Number	:	805-766-1049
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2013
Last Update Date	:	11/10/2023

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