Basic Information
| Provider Information | |||||||||
| NPI: | 1962686022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STICKWAN | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 713 CHIEF RICHARD CARL SR. DRIVE | ||||||||
| Address2: | |||||||||
| City: | CRAIG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078262628 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7300 KLAWOCK-HOLLIS HWY. | ||||||||
| Address2: | |||||||||
| City: | KLAWOCK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077554800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 12/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 27807 | AK | Y | Nursing Service Providers | Registered Nurse |
No ID Information.