Provider Demographics
NPI:1679563829
Name:ATTLA, MARILYN ELAINE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:ELAINE
Last Name:ATTLA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:MARILYN
Other - Middle Name:ELAINE
Other - Last Name:ATTLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:1717 W. COWLES ST.
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-451-6682
Mailing Address - Fax:907-574-3922
Practice Address - Street 1:1717 W COWLES ST
Practice Address - Street 2:C.A.I.H.C.
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5926
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:907-459-3817
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK320363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0401Medicaid