Provider Demographics
NPI:1710262761
Name:LACROSS, MEGAN L (BA)
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:L
Last Name:LACROSS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-0331
Mailing Address - Country:US
Mailing Address - Phone:907-262-7504
Mailing Address - Fax:907-262-9422
Practice Address - Street 1:44539 STERLING HWY
Practice Address - Street 2:STE.206
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7938
Practice Address - Country:US
Practice Address - Phone:907-262-7504
Practice Address - Fax:907-262-9422
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCMG632171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG632Medicaid