Provider Demographics
NPI:1942991930
Name:LACANLALE, ISMAEL (PTA)
Entity Type:Individual
Prefix:
First Name:ISMAEL
Middle Name:
Last Name:LACANLALE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 W LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-4910
Mailing Address - Country:US
Mailing Address - Phone:907-887-9802
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE OTIS PKWY STE 106
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5230
Practice Address - Country:US
Practice Address - Phone:907-563-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK202494225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant