Basic Information
| Provider Information | |||||||||
| NPI: | 1821365552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANIILAQ ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SELAWIK CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 43 | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427150 | ||||||||
| FaxNumber: | 9074427250 | ||||||||
| Practice Location | |||||||||
| Address1: | #3 ADAMS LANDING-OLD | ||||||||
| Address2: | |||||||||
| City: | SELAWIK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074842199 | ||||||||
| FaxNumber: | 9074842119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2011 | ||||||||
| LastUpdateDate: | 11/23/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9074457150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MANIILAQ ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal |
No ID Information.