Basic Information
| Provider Information | |||||||||
| NPI: | 1346536505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HESS | ||||||||
| FirstName: | CORTNEY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOULTON | ||||||||
| OtherFirstName: | CORTNEY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 589 | ||||||||
| Address2: | PETERSBURG MEDICAL CENTER | ||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072126522 | ||||||||
| FaxNumber: | 9072126593 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 FRAM ST | ||||||||
| Address2: | PETERSBURG MEDICAL CENTER | ||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077724291 | ||||||||
| FaxNumber: | 9077723085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 07/02/2014 | ||||||||
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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 | 207Q00000X | 6087 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD9638 | 05 | AK | MEDICAID |