Basic Information
| Provider Information | |||||||||
| NPI: | 1861415622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIANG | ||||||||
| FirstName: | SHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 DAVIS RD APT C7 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074600222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 COWLES ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009459877 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 5387 | AK | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | MD2985 | 05 | AK | MEDICAID |