Provider Demographics
NPI:1962761973
Name:MUNGER, TREVOR DALE (CPO)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:DALE
Last Name:MUNGER
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 LAKE OTIS PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1778
Mailing Address - Country:US
Mailing Address - Phone:907-743-9991
Mailing Address - Fax:907-743-9992
Practice Address - Street 1:1700 E BOGARD RD STE 104
Practice Address - Street 2:BUILDING B
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6563
Practice Address - Country:US
Practice Address - Phone:907-743-9991
Practice Address - Fax:907-743-9992
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECPO01700222Z00000X, 224L00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist