Basic Information
Provider Information | |||||||||
NPI: | 1063917177 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOELLING | ||||||||
FirstName: | CAITLIN | ||||||||
MiddleName: | JUSTINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARRENT | ||||||||
OtherFirstName: | CAITLIN | ||||||||
OtherMiddleName: | JUSTINE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2250 E 42ND AVE # 200 | ||||||||
Address2: |   | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995085202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075693668 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3190 E MERIDIAN PARK LOOP STE 205 | ||||||||
Address2: |   | ||||||||
City: | WASILLA | ||||||||
State: | AK | ||||||||
PostalCode: | 996547422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075693668 | ||||||||
FaxNumber: | 9075693669 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2018 | ||||||||
LastUpdateDate: | 08/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 173700 | AK | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.