Provider Demographics
NPI:1518515030
Name:GLACIER BAY MEDICAL AND DIABETES CARE CENTER LLC
Entity Type:Organization
Organization Name:GLACIER BAY MEDICAL AND DIABETES CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, NP-C
Authorized Official - Phone:907-290-4566
Mailing Address - Street 1:615 E 82ND AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-3159
Mailing Address - Country:US
Mailing Address - Phone:907-290-4566
Mailing Address - Fax:
Practice Address - Street 1:615 E 82ND AVE STE 302
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-3159
Practice Address - Country:US
Practice Address - Phone:907-290-4566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty