Basic Information
| Provider Information | |||||||||
| NPI: | 1598431058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PLATT | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1175 VICKI LN APT B | ||||||||
| Address2: | |||||||||
| City: | NORTH POLE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997055991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108894935 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3101 LATHROP ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997017426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074594700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2021 | ||||||||
| LastUpdateDate: | 02/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 106S00000X | AK | Y |
No ID Information.