Provider Demographics
NPI:1689391294
Name:BOSTWICK, LAURA MARIE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:BOSTWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ROCKMORE-KING CLINIC
Mailing Address - Street 2:PO BOX 195002 BLDG N46
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 CAPE SARICHEF
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-487-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01580171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider