Provider Demographics
NPI:1992037154
Name:PAN ALASKA PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PAN ALASKA PHYSICAL THERAPY
Other - Org Name:EAGLE CENTER PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSDICK
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:1907-696-5678
Mailing Address - Street 1:11470 BUSINESS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7780
Mailing Address - Country:US
Mailing Address - Phone:907-696-5678
Mailing Address - Fax:907-696-2248
Practice Address - Street 1:11470 BUSINESS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7780
Practice Address - Country:US
Practice Address - Phone:907-696-5678
Practice Address - Fax:907-696-2248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2125261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy