Basic Information
| Provider Information | |||||||||
| NPI: | 1508187360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 481 PASO DE MONTANA ST | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891381130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022920531 | ||||||||
| FaxNumber: | 7028778770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 NOBLE ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074593500 | ||||||||
| FaxNumber: | 9074593526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2010 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | SL0755 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 7829 | AK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO1759 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1585553 | 05 | AK | MEDICAID |