Provider Demographics
NPI:1508121047
Name:FAIRWEATHER DEADHORSE MEDICAL CLINIC
Entity Type:Organization
Organization Name:FAIRWEATHER DEADHORSE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOLAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-248-8008
Mailing Address - Street 1:PO BOX 200134
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99520-0134
Mailing Address - Country:US
Mailing Address - Phone:907-248-8008
Mailing Address - Fax:907-248-8208
Practice Address - Street 1:500 1ST STREET
Practice Address - Street 2:
Practice Address - City:DEADHORSE
Practice Address - State:AK
Practice Address - Zip Code:99734-0000
Practice Address - Country:US
Practice Address - Phone:907-685-1800
Practice Address - Fax:907-685-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK940479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty