Basic Information
| Provider Information | |||||||||
| NPI: | 1235581885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LITTLE EAGLE | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3550 AIRPORT WAY | ||||||||
| Address2: | 4 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074792331 | ||||||||
| FaxNumber: | 9074790164 | ||||||||
| Practice Location | |||||||||
| Address1: | 3550 AIRPORT WAY | ||||||||
| Address2: | 4 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997094772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074792331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2016 | ||||||||
| LastUpdateDate: | 07/07/2016 | ||||||||
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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 | 171100000X | ACUA25 | AK | Y | Other Service Providers | Acupuncturist |
ID Information
| ID | Type | State | Issuer | Description | 1643831 | 05 | AK | MEDICAID |