Provider Demographics
NPI:1881287951
Name:BISHOP, TOMMIE L
Entity type:Individual
Prefix:MR
First Name:TOMMIE
Middle Name:L
Last Name:BISHOP
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:PO BOX 202056
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99520-2056
Mailing Address - Country:US
Mailing Address - Phone:907-223-6377
Mailing Address - Fax:
Practice Address - Street 1:1533 LATOUCHE ST APT C
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-5588
Practice Address - Country:US
Practice Address - Phone:907-272-6377
Practice Address - Fax:866-496-4107
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1010173104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1871195420Medicaid