Provider Demographics
NPI:1053344572
Name:PROVOST, ELLEN MICHELLE (DO)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MICHELLE
Last Name:PROVOST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 DIPLOMACY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5926
Mailing Address - Country:US
Mailing Address - Phone:907-729-1500
Mailing Address - Fax:907-729-2082
Practice Address - Street 1:4315 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5926
Practice Address - Country:US
Practice Address - Phone:907-729-1500
Practice Address - Fax:907-729-2082
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2717207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD27172Medicaid
AK8EC686Medicare ID - Type Unspecified
AKMD27172Medicaid