Provider Demographics
NPI:1497942585
Name:KORSGREN, THEODORE YNGVE III (LPN)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:YNGVE
Last Name:KORSGREN
Suffix:III
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W. COWLES ST.
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5903
Mailing Address - Country:US
Mailing Address - Phone:907-451-6682
Mailing Address - Fax:
Practice Address - Street 1:1717 W. COWLES ST.
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5903
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5364164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse