Provider Demographics
NPI:1255410213
Name:ILLIG, PETRA ANDREA (MD)
Entity type:Individual
Prefix:DR
First Name:PETRA
Middle Name:ANDREA
Last Name:ILLIG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5011 SPENARD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-3320
Mailing Address - Country:US
Mailing Address - Phone:907-245-4359
Mailing Address - Fax:907-245-2212
Practice Address - Street 1:5011 SPENARD RD STE 102
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99517-3320
Practice Address - Country:US
Practice Address - Phone:907-245-4359
Practice Address - Fax:907-245-2212
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK4193209800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAC94379Medicare UPIN