Provider Demographics
NPI:1467523779
Name:PAN ALASKA PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PAN ALASKA PHYSICAL THERAPY, INC.
Other - Org Name:WASILLA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:FOSDICK
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:907-376-7334
Mailing Address - Street 1:3750 E COUNTRY FIELD CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6689
Mailing Address - Country:US
Mailing Address - Phone:907-376-7334
Mailing Address - Fax:907-373-1429
Practice Address - Street 1:3750 E COUNTRY FIELD CIR
Practice Address - Street 2:SUITE A
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6689
Practice Address - Country:US
Practice Address - Phone:907-376-7334
Practice Address - Fax:907-373-1429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT07162Medicaid
AKK0000WCKJNMedicare PIN