Basic Information
| Provider Information | |||||||||
| NPI: | 1871606004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORMAN | ||||||||
| FirstName: | PAUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 E BOGARD RD STE 233 | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762273 | ||||||||
| FaxNumber: | 9077331735 | ||||||||
| Practice Location | |||||||||
| Address1: | 34300 TALKEETNA S SPUR RD | ||||||||
| Address2: | |||||||||
| City: | TALKEETNA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077332273 | ||||||||
| FaxNumber: | 9077331735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3728 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD44651 | 05 | AK | MEDICAID | P00115873 | 01 | AK | RAILROAD MEDICARE PIN# | OTHER |