Provider Demographics
NPI:1073653424
Name:FIREWEED HEALTH CARE CLINIC INC
Entity type:Organization
Organization Name:FIREWEED HEALTH CARE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CW
Authorized Official - Middle Name:
Authorized Official - Last Name:JASPER
Authorized Official - Suffix:
Authorized Official - Credentials:ANP, ND
Authorized Official - Phone:907-276-4611
Mailing Address - Street 1:3944 SPENARD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-3003
Mailing Address - Country:US
Mailing Address - Phone:907-276-4611
Mailing Address - Fax:
Practice Address - Street 1:3944 SPENARD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99517-3003
Practice Address - Country:US
Practice Address - Phone:907-276-4611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK=========OtherTAX ID #