Provider Demographics
NPI:1124558044
Name:ALASKA PEDIATRIC NIGHT CLINIC, INC.
Entity Type:Organization
Organization Name:ALASKA PEDIATRIC NIGHT CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:907-201-7801
Mailing Address - Street 1:20209 EAGLE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-6800
Mailing Address - Country:US
Mailing Address - Phone:907-201-7801
Mailing Address - Fax:
Practice Address - Street 1:20209 EAGLE RIVER RD
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-6800
Practice Address - Country:US
Practice Address - Phone:907-201-7801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK113174208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK129450Medicaid