Basic Information
Provider Information | |||||||||
NPI: | 1730204413 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BABARA A WORTMAN, RNFA | ||||||||
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: | 9077702301 | ||||||||
FaxNumber: | 9077702325 | ||||||||
Practice Location | |||||||||
Address1: | 21134 LOWLAND AVE | ||||||||
Address2: |   | ||||||||
City: | EAGLE RIVER | ||||||||
State: | AK | ||||||||
PostalCode: | 995779584 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9076967670 | ||||||||
FaxNumber: | 9075506179 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEATY | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING AGENT | ||||||||
AuthorizedOfficialTelephone: | 9077702301 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SM0705X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Medical-Surgical |
No ID Information.