Provider Demographics
NPI:1184997108
Name:AGUCHAK, MARY PAULINE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PAULINE
Last Name:AGUCHAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:PAULINE
Other - Last Name:YUNAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:97 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:SCAMMON BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99662-0097
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 MAIN RD
Practice Address - Street 2:SCAMMON BAY CLINIC
Practice Address - City:SCAMMON BAY
Practice Address - State:AK
Practice Address - Zip Code:99662-0150
Practice Address - Country:US
Practice Address - Phone:907-558-5511
Practice Address - Fax:907-558-5705
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK9439Medicaid