Provider Demographics
NPI:1881109767
Name:BROWN, MICHAEL ANTHONY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:BROWN
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 1:400 W 76TH AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-2551
Mailing Address - Country:US
Mailing Address - Phone:907-229-1575
Mailing Address - Fax:866-413-7297
Practice Address - Street 1:7940 LITTLE DIPPER AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4125
Practice Address - Country:US
Practice Address - Phone:907-337-2331
Practice Address - Fax:866-413-7297
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1677044Medicaid