1528039336 NPI number — KAREN SHIRA OP

Table of content: KAREN SHIRA OP (NPI 1528039336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528039336 NPI number — KAREN SHIRA OP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIRA
Provider First Name:
KAREN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528039336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 241769
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99524-1769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-770-2380
Provider Business Mailing Address Fax Number:
909-770-2390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 LATHROP ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-478-4091
Provider Business Practice Location Address Fax Number:
907-451-7184
Provider Enumeration Date:
01/30/2006

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: 156FX1800X , with the licence number:  DOP D 44 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0194434 . This is a "DEPT OF LABOR GROUP" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: A0330 . This is a "BLUE CROSS" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: OP0593 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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