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282 Bentley Trust Road Suite B Fairbanks AK 99701 | |
| (907) 744-1944 | |
| (907) 921-7669 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 282 Bentley Trust Road Suite B, Fairbanks, Alaska |
| Authorized Official Name and Position | Lisa Bruce (COO) |
| Authorized Official Contact | 9077441944 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
510 W Tudor Rd Ste1 Anchorage AK 99503-6649 Ph: (907) 744-1944 | 282 Bentley Trust Road Suite B Fairbanks AK 99701 Ph: (907) 744-1944 |
| NPI Number | 1134990336 |
|---|---|
| Provider Enumeration Date | 01/16/2024 |
| Last Update Date | 01/23/2025 |
| Medicare PECOS PAC ID | 2163963463 |
|---|---|
| Medicare Enrollment ID | O20240925004279 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1134990336 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| Provider Name | Jeffrey G Demain |
|---|---|
| Provider Type | Practitioner - Allergy/immunology |
| Provider Identifiers | NPI Number: 1548201395 PECOS PAC ID: 7810989399 Enrollment ID: I20040706000728 |
| Provider Name | Melissa Van Fossen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1235837865 PECOS PAC ID: 6204291792 Enrollment ID: I20230505002290 |
| Provider Name | Cielito Marie Bundang Bowen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1437921095 PECOS PAC ID: 9638528060 Enrollment ID: I20231212000051 |
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