Provider Demographics
NPI:1710194709
Name:SANMIGUEL, JUAN (CC)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:SANMIGUEL
Suffix:
Gender:M
Credentials:CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W NORTHERN LIGHTS BLVD
Mailing Address - Street 2:#234
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2501
Mailing Address - Country:US
Mailing Address - Phone:907-771-4010
Mailing Address - Fax:907-771-4020
Practice Address - Street 1:555 W NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2501
Practice Address - Country:US
Practice Address - Phone:907-771-4010
Practice Address - Fax:907-771-4020
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM8547Medicaid