Basic Information
| Provider Information | |||||||||
| NPI: | 1871529628 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YAKUTAT TRIBAL HEALTH BOARD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | YAKUTAT COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 112 | ||||||||
| Address2: | |||||||||
| City: | YAKUTAT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996890112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077843275 | ||||||||
| FaxNumber: | 9077843263 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | YAKUTAT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077843275 | ||||||||
| FaxNumber: | 9077843263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | WASSILLIE | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9077843275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261Q00000X | 288254 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | MEDICAID | 05 | AK | MEDICAID |