Basic Information
| Provider Information | |||||||||
| NPI: | 1679772735 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTH WORKS FAMILY MEDICAL CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12812 OLD GLENN HWY SUITE A7 | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077702301 | ||||||||
| FaxNumber: | 9077702325 | ||||||||
| Practice Location | |||||||||
| Address1: | 12812 OLD GLENN HWY STE A7 | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076229675 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 04/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | EGBERT | ||||||||
| AuthorizedOfficialFirstName: | MARY ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9076229675 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | A.N.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | MPG0003 | 05 | AK | MEDICAID |