Provider Demographics
NPI:1356822712
Name:FATTYHYDARA, OUSMAN
Entity Type:Individual
Prefix:
First Name:OUSMAN
Middle Name:
Last Name:FATTYHYDARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:848 ELAINE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-2234
Mailing Address - Country:US
Mailing Address - Phone:907-229-2056
Mailing Address - Fax:
Practice Address - Street 1:848 ELAINE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-2234
Practice Address - Country:US
Practice Address - Phone:907-229-2056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1034167311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility