Provider Demographics
NPI:1801174586
Name:FAMILY DIABETES CLINIC
Entity type:Organization
Organization Name:FAMILY DIABETES CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MICHALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-677-3750
Mailing Address - Street 1:1407 W 31ST AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-3678
Mailing Address - Country:US
Mailing Address - Phone:907-677-3750
Mailing Address - Fax:907-677-3751
Practice Address - Street 1:1407 W 31ST AVE
Practice Address - Street 2:STE. 600
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3678
Practice Address - Country:US
Practice Address - Phone:907-677-3750
Practice Address - Fax:907-677-3751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK688364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMPG0391Medicaid