Basic Information
| Provider Information | |||||||||
| NPI: | 1184997108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGUCHAK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | PAULINE | ||||||||
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| OtherLastName: | YUNAK | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | PAULINE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 97 HILLSIDE RD | ||||||||
| Address2: | |||||||||
| City: | SCAMMON BAY | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996620097 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 MAIN RD | ||||||||
| Address2: | SCAMMON BAY CLINIC | ||||||||
| City: | SCAMMON BAY | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996620150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075585511 | ||||||||
| FaxNumber: | 9075585705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2012 | ||||||||
| LastUpdateDate: | 12/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
ID Information
| ID | Type | State | Issuer | Description | 9439 | 05 | AK | MEDICAID |