Provider Demographics
NPI:1174177943
Name:EGRASS, PAULINE ALEXANDRIA
Entity type:Individual
Prefix:MRS
First Name:PAULINE
Middle Name:ALEXANDRIA
Last Name:EGRASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAULINE
Other - Middle Name:ALEXANDRIA
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MC GRATH
Mailing Address - State:AK
Mailing Address - Zip Code:99627-0010
Mailing Address - Country:US
Mailing Address - Phone:907-524-3299
Mailing Address - Fax:907-524-3805
Practice Address - Street 1:10 DNR RD
Practice Address - Street 2:
Practice Address - City:MC GRATH
Practice Address - State:AK
Practice Address - Zip Code:99627-0010
Practice Address - Country:US
Practice Address - Phone:907-524-3299
Practice Address - Fax:907-524-3805
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK19-1564-I172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker