Provider Demographics
NPI:1699737692
Name:VANCE, KERRY DEAN (MD)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:DEAN
Last Name:VANCE
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 1:4300 B ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-5933
Mailing Address - Country:US
Mailing Address - Phone:907-375-3355
Mailing Address - Fax:907-375-3351
Practice Address - Street 1:2500 S WOODWORTH LOOP
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8984
Practice Address - Country:US
Practice Address - Phone:907-375-3355
Practice Address - Fax:907-375-3351
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5367207Q00000X
MO2012025753207Q00000X
AK7596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1314130-08Medicaid
TX8U1465OtherBLUE SHIELD
TX8CD653OtherBC/BS
TX1314130-09OtherCSHCN
TX131413010Medicaid
TX8G0599Medicare ID - Type Unspecified
TX8L21443Medicare PIN
TX131413010Medicaid