Basic Information
| Provider Information | |||||||||
| NPI: | 1902150139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANSON | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C, ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KUCKO | ||||||||
| OtherFirstName: | KERRY | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3066 E MERIDIAN PARK LOOP | ||||||||
| Address2: | STE 3 | ||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996547254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073579590 | ||||||||
| FaxNumber: | 9073579593 | ||||||||
| Practice Location | |||||||||
| Address1: | 17025 SNOWMOBILE LN | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076949553 | ||||||||
| FaxNumber: | 9076949585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2012 | ||||||||
| LastUpdateDate: | 09/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1073 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.