Provider Demographics
NPI:1205693298
Name:SUNDER, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SUNDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12812 OLD GLENN HWY
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7002
Mailing Address - Country:US
Mailing Address - Phone:907-696-8020
Mailing Address - Fax:907-696-8017
Practice Address - Street 1:12812 OLD GLENN HWY
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7002
Practice Address - Country:US
Practice Address - Phone:907-696-8020
Practice Address - Fax:907-696-8017
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2013355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist