Basic Information
Provider Information | |||||||||
NPI: | 1427665280 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALASKA MONITORING ASSOCIATES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 241769 | ||||||||
Address2: |   | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995241769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9077702380 | ||||||||
FaxNumber: | 9077702341 | ||||||||
Practice Location | |||||||||
Address1: | 11641 WOODBOURNE DR | ||||||||
Address2: |   | ||||||||
City: | ANCHORAGE | ||||||||
State: | AK | ||||||||
PostalCode: | 995161279 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9077192898 | ||||||||
FaxNumber: | 9077719715 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2020 | ||||||||
LastUpdateDate: | 09/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PUTNAM | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9072306063 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
ID Information
ID | Type | State | Issuer | Description | 1041077 | 01 | AK | ALASKA BUSINESS LICENSE | OTHER |