Basic Information
| Provider Information | |||||||||
| NPI: | 1205355369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANDY | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | CACHE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3066 E MERIDIAN PARK LOOP STE 3 | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073579590 | ||||||||
| FaxNumber: | 9073579593 | ||||||||
| Practice Location | |||||||||
| Address1: | 4361 BONIFACE PKWY STE 3 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995044316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073739462 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2017 | ||||||||
| LastUpdateDate: | 09/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 125568 | AK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 125568 | 01 | AK | STATE OF ALASKA PROFESSIONAL LICENSE | OTHER |