Provider Demographics
NPI:1770553497
Name:GONIOTAKIS, STEVE T (PAC)
Entity type:Individual
Prefix:
First Name:STEVE
Middle Name:T
Last Name:GONIOTAKIS
Suffix:
Gender:M
Credentials:PAC
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 481
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:AK
Mailing Address - Zip Code:99672-0481
Mailing Address - Country:US
Mailing Address - Phone:907-262-2355
Mailing Address - Fax:
Practice Address - Street 1:110 NICHOLOFF WAY
Practice Address - Street 2:ILANKA HEALTH CLINIC
Practice Address - City:CORDOVA
Practice Address - State:AK
Practice Address - Zip Code:99574
Practice Address - Country:US
Practice Address - Phone:907-424-3622
Practice Address - Fax:907-424-3681
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL7624Medicaid
AKCL7624Medicaid
S98862Medicare UPIN