Basic Information
| Provider Information | |||||||||
| NPI: | 1922218635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVILA | ||||||||
| FirstName: | PATRICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 528 | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436100 | ||||||||
| FaxNumber: | 9075436008 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 CHIEF EDDY HOFFMAN HWY | ||||||||
| Address2: | |||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436100 | ||||||||
| FaxNumber: | 9075436008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | DA4442 | 05 | AK | MEDICAID |