Provider Demographics
NPI:1689711715
Name:PUHAK, PENNY K (ETC)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:K
Last Name:PUHAK
Suffix:
Gender:F
Credentials:ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CENTER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6393
Mailing Address - Country:US
Mailing Address - Phone:907-486-4183
Mailing Address - Fax:907-486-4233
Practice Address - Street 1:104 CENTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6393
Practice Address - Country:US
Practice Address - Phone:907-486-4183
Practice Address - Fax:907-486-4233
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1532Medicaid
AKGR0124Medicaid
AKMD1532Medicaid
AKQ77839Medicare UPIN