Provider Demographics
NPI:1568018158
Name:MARTINO, MOKSHA (APRN)
Entity Type:Individual
Prefix:MS
First Name:MOKSHA
Middle Name:
Last Name:MARTINO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:MOKSHA
Other - Middle Name:
Other - Last Name:BODE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:5912 PROSPERITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3264
Mailing Address - Country:US
Mailing Address - Phone:907-250-0127
Mailing Address - Fax:
Practice Address - Street 1:3700 PIPER ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4665
Practice Address - Country:US
Practice Address - Phone:907-269-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-10
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK147969363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020586Medicaid