Provider Demographics
NPI:1487778304
Name:JACONETTE, ANDREW RICHARD (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:RICHARD
Last Name:JACONETTE
Suffix:
Gender:M
Credentials:MD
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 210850
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99521-0850
Mailing Address - Country:US
Mailing Address - Phone:907-677-6900
Mailing Address - Fax:907-677-6999
Practice Address - Street 1:851 E WESTPOINT DR
Practice Address - Street 2:SUITE 203
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7191
Practice Address - Country:US
Practice Address - Phone:907-373-7934
Practice Address - Fax:907-677-6999
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5328207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1016497Medicaid
K168084Medicare PIN
AKH14138Medicare UPIN
AK63804Medicaid