Basic Information
| Provider Information | |||||||||
| NPI: | 1497942585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORSGREN | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | YNGVE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 W. COWLES ST. | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1717 W. COWLES ST. | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 12/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 5364 | AK | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.