1184997108 NPI number — MARY PAULINE AGUCHAK

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184997108 NPI number — MARY PAULINE AGUCHAK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGUCHAK
Provider First Name:
MARY
Provider Middle Name:
PAULINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YUNAK
Provider Other First Name:
MARY
Provider Other Middle Name:
PAULINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184997108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
97 HILLSIDE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCAMMON BAY
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99662-0097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 MAIN RD
Provider Second Line Business Practice Location Address:
SCAMMON BAY CLINIC
Provider Business Practice Location Address City Name:
SCAMMON BAY
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99662-0150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-558-5511
Provider Business Practice Location Address Fax Number:
907-558-5705
Provider Enumeration Date:
02/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 247200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9439 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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