Provider Demographics
NPI:1679139596
Name:EMPOWER MEDICAL AND WELLNESS
Entity Type:Organization
Organization Name:EMPOWER MEDICAL AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TYFANAE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRINKE
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-315-4042
Mailing Address - Street 1:1150 S COLONY WAY
Mailing Address - Street 2:STE 3 PMB 568
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6967
Mailing Address - Country:US
Mailing Address - Phone:907-315-4042
Mailing Address - Fax:907-313-1417
Practice Address - Street 1:1901 N HEMMER RD STE 211
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-9690
Practice Address - Country:US
Practice Address - Phone:907-315-4042
Practice Address - Fax:907-313-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-16
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1652161Medicaid