Provider Demographics
NPI:1205958287
Name:STATE OF ALASKA
Entity type:Organization
Organization Name:STATE OF ALASKA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:VIOLA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HAROSIA
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:907-352-6650
Mailing Address - Street 1:3223 PALMER WASILLA HWY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7236
Mailing Address - Country:US
Mailing Address - Phone:907-352-6600
Mailing Address - Fax:907-376-3096
Practice Address - Street 1:3223 PALMER WASILLA HWY
Practice Address - Street 2:SUITE 3
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7236
Practice Address - Country:US
Practice Address - Phone:907-352-6600
Practice Address - Fax:907-376-3096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK529251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNPO529PH0529Medicaid
AK8EZ91LMedicare ID - Type Unspecified
AKS65841Medicare UPIN