Provider Demographics
NPI:1922073188
Name:POMEROY, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:POMEROY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 KELLUM ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4189
Mailing Address - Country:US
Mailing Address - Phone:907-374-4636
Mailing Address - Fax:907-374-4853
Practice Address - Street 1:1405 KELLUM ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4189
Practice Address - Country:US
Practice Address - Phone:907-374-4636
Practice Address - Fax:907-374-4853
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK179363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP0750023OtherDEA NUMBER
MP0750023OtherDEA NUMBER
AKK151702Medicare PIN