Provider Demographics
NPI:1902232366
Name:LAND, JIM T (CSA)
Entity Type:Individual
Prefix:MR
First Name:JIM
Middle Name:T
Last Name:LAND
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1700 E BOGARD RD STE 120
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6563
Mailing Address - Country:US
Mailing Address - Phone:907-357-2267
Mailing Address - Fax:907-563-3460
Practice Address - Street 1:1700 E BOGARD RD STE 120
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6563
Practice Address - Country:US
Practice Address - Phone:907-357-2267
Practice Address - Fax:907-563-3460
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
AK3336246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant