Provider Demographics
NPI:1962431122
Name:AHLSTROM, NANCY G (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:G
Last Name:AHLSTROM
Suffix:
Gender:F
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 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-565-9237
Mailing Address - Fax:360-457-7318
Practice Address - Street 1:939 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3909
Practice Address - Country:US
Practice Address - Phone:360-417-7793
Practice Address - Fax:360-417-7318
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60442392207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE54026Medicare UPIN
UT005502524Medicare ID - Type UnspecifiedMEDICARE
UT8702810028000Medicaid
UT107006985101OtherIHC
UT390007962OtherPALMETTO
UTE54026Medicare UPIN
UT870281028AH1OtherEMIA
UTQM0000044583OtherALTIUS
UT005502524Medicare ID - Type UnspecifiedMEDICARE
UT124956OtherDMBA