Basic Information
| Provider Information | |||||||||
| NPI: | 1811093743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANDERWICK | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | BAKKER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAKKER | ||||||||
| OtherFirstName: | ANNE | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 641 W WILLOUGHBY AVE | ||||||||
| Address2: | #201 | ||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075868100 | ||||||||
| FaxNumber: | 9075868102 | ||||||||
| Practice Location | |||||||||
| Address1: | 641 W WILLOUGHBY AVE | ||||||||
| Address2: | #201 | ||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075868100 | ||||||||
| FaxNumber: | 9075868102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4033 | AK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD9819 | 05 | AK | MEDICAID |