Basic Information
| Provider Information | |||||||||
| NPI: | 1053320531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORDE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 69 | ||||||||
| Address2: | |||||||||
| City: | KLAWOCK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999250069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072540850 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7300 KLAWOCK-HOLLIS HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | KLAWOCK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999250069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077554800 | ||||||||
| FaxNumber: | 9077554981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 01/08/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 2831 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 981 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MDA0419 | 05 | AK | MEDICAID | PA 2831 | 01 | FL | FLORIDA LICENSE PA-C | OTHER | 981 | 01 | AK | ALASKA LICENSE | OTHER |