Basic Information
Provider Information | |||||||||
NPI: | 1194720250 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHRISTENSEN | ||||||||
FirstName: | ALAN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986838004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072287688 | ||||||||
FaxNumber: | 9072288468 | ||||||||
Practice Location | |||||||||
Address1: | 3100 TONGASS AVE | ||||||||
Address2: |   | ||||||||
City: | KETCHIKAN | ||||||||
State: | AK | ||||||||
PostalCode: | 999015746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072287688 | ||||||||
FaxNumber: | 9072288468 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2005 | ||||||||
LastUpdateDate: | 03/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 172326-1205 | UT | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 13746 | MS | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 41260 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 73823 | 01 | UT | PEHP | OTHER | 7100018700 | 05 | KY |   | MEDICAID | 806638800 | 01 | ID | IDAHO MEDICAID | OTHER | 17232612000001 | 01 | UT | BLUE CROSS BLUE SHIELD | OTHER | QM0000068942 | 01 | UT | ALTIUS | OTHER |