Provider Demographics
NPI:1578957460
Name:BECKER, MARA JUSTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:JUSTINE
Last Name:BECKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4871
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:907-459-3950
Practice Address - Street 1:1717 W. COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK- ALASKA
Practice Address - Zip Code:99701
Practice Address - Country:UM
Practice Address - Phone:907-452-8251
Practice Address - Fax:907-459-3950
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60535341363A00000X
AK2418363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant