Basic Information
| Provider Information | |||||||||
| NPI: | 1982035325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TROSPER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634074 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 SALMON CREEK LANE | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634040 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2013 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | N | Other Service Providers | Military Health Care Provider | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA3575 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 171614 | 01 | AK | OCCUPATIONAL LICENSE | OTHER |