Provider Demographics
NPI:1528039336
Name:SHIRA, KAREN (OP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:SHIRA
Suffix:
Gender:F
Credentials:OP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 241769
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99524-1769
Mailing Address - Country:US
Mailing Address - Phone:909-770-2380
Mailing Address - Fax:909-770-2390
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:SUITE 103
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:800-478-4091
Practice Address - Fax:907-451-7184
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKDOP D 44156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK0194434OtherDEPT OF LABOR GROUP
AKA0330OtherBLUE CROSS
AKOP0593Medicaid
AK0194434OtherDEPT OF LABOR GROUP