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1275 Sadler Way Ste 104 Fairbanks AK 99701-3175 | |
| (907) 921-5511 | |
| (907) 921-3574 |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 1275 Sadler Way Ste 104, Fairbanks, Alaska |
| Authorized Official Name and Position | Kelly Rae Johnson (CREDENTIALING DIRECTOR) |
| Authorized Official Contact | 7853206616 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1275 Sadler Way Ste 102 Fairbanks AK 99701-3175 Ph: (907) 921-5511 | 1275 Sadler Way Ste 104 Fairbanks AK 99701-3175 Ph: (907) 921-5511 |
| NPI Number | 1144927096 |
|---|---|
| Provider Enumeration Date | 02/10/2023 |
| Last Update Date | 11/20/2024 |
| Certification Date | 11/20/2024 |
| Medicare PECOS PAC ID | 4880046879 |
|---|---|
| Medicare Enrollment ID | O20240116000030 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1144927096 | NPI | - | NPPES |
| Provider Name | Kirk Stoner |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1437844909 PECOS PAC ID: 6709230113 Enrollment ID: I20241008004127 |
| Provider Name | Darian J Hawke |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1407553167 PECOS PAC ID: 9335673797 Enrollment ID: I20241108000400 |
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