Provider Demographics
NPI:1801475314
Name:IRWIN, NETTIE O L (MD)
Entity type:Individual
Prefix:
First Name:NETTIE
Middle Name:O L
Last Name:IRWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NETTIE
Other - Middle Name:O
Other - Last Name:IRWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 73720
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3720
Mailing Address - Country:US
Mailing Address - Phone:907-459-3520
Mailing Address - Fax:907-459-3554
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5907
Practice Address - Country:US
Practice Address - Phone:907-459-3520
Practice Address - Fax:907-459-3554
Is Sole Proprietor?:No
Enumeration Date:2021-04-03
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12974710-1205208000000X
AK228059208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1752819Medicaid