Provider Demographics
NPI:1588651053
Name:DALE, THOMAS MANFORD III (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MANFORD
Last Name:DALE
Suffix:III
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 OLD STEESE HWY
Mailing Address - Street 2:SUITE B PMB255
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3131
Mailing Address - Country:US
Mailing Address - Phone:907-388-0748
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5925
Practice Address - Country:US
Practice Address - Phone:907-458-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK475363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01977Medicare UPIN
AK161398Medicare PIN
AK151130Medicare UPIN