Basic Information
| Provider Information | |||||||||
| NPI: | 1770887101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YODER | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ANP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALANAPHY | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | ANP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 200149 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995200149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075613211 | ||||||||
| FaxNumber: | 9075627547 | ||||||||
| Practice Location | |||||||||
| Address1: | 3841 PIPER ST | ||||||||
| Address2: | SUITE T100 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075613211 | ||||||||
| FaxNumber: | 9075627547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2010 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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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 | 363LF0000X | 1185 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1571397 | 05 | AK | MEDICAID |