Basic Information
| Provider Information | |||||||||
| NPI: | 1316272032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINLEY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 MINNIE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074567760 | ||||||||
| FaxNumber: | 9074517916 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 MINNIE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074567760 | ||||||||
| FaxNumber: | 9074517916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2009 | ||||||||
| LastUpdateDate: | 08/07/2013 | ||||||||
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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 | 152W00000X | A-131 | AK | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | O-548 | ID | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | OD 2131 | 05 | AK | MEDICAID |