Basic Information
| Provider Information | |||||||||
| NPI: | 1669666905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COON | ||||||||
| FirstName: | JOY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARVEY | ||||||||
| OtherFirstName: | JOY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | O.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| 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: | 08/29/2007 | ||||||||
| LastUpdateDate: | 02/16/2011 | ||||||||
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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 | 156FX1800X | 272 | AK | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | OP4810 | 05 | AK | MEDICAID |