Basic Information
| Provider Information | |||||||||
| NPI: | 1306811559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NACE | ||||||||
| FirstName: | MISHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 NOBLE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593500 | ||||||||
| FaxNumber: | 9074593554 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 NOBLE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593520 | ||||||||
| FaxNumber: | 9074593554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 10/31/2016 | ||||||||
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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 | 208000000X | 3836 | AK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1012552 | 05 | AK | MEDICAID | BN3766891 | 01 | DEA NUMBER | OTHER |