Cottonwood Creek Clinic LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

1011473 Issued in AK

Legal business name

COTTONWOOD CREEK CLINIC LLC

Practice address

3600 E Wickersham Way
Wasilla, AK 99654-7550

Phone

(907) 373-5950

Fax

(907) 373-5954

NPI assigned

Oct 9, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Richard BlakeNPI 1740235829

Title

Owner

Phone

(907) 373-5950

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in AK

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Richard W. Blake, PA-C

  • Medical Physician Assistant
  • Wasilla, AK
  • NPI 1740235829
  Medicare reassignment Care Compare group Authorized official
• Katherine Nevin Naylor, MD

  • Hospitalist Physician
  • Palmer, AK
  • NPI 1013938729
  Medicare reassignment Care Compare group NPD
• Tamara Simpson, ANP

  • Nurse Practitioner
  • Wasilla, AK
  • NPI 1881128643
  Medicare reassignment Care Compare group NPD
• John Wayne Moore, PA-C

  • Medical Physician Assistant
  • Wasilla, AK
  • NPI 1669552550
  Medicare reassignment Care Compare group

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1412812800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678147200000",
    "number": "1134523855",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3600 E WICKERSHAM WAY",
            "city": "WASILLA",
            "state": "AK",
            "postal_code": "996547550",
            "telephone_number": "907-373-5950",
            "fax_number": "907-373-5954"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3600 E WICKERSHAM WAY",
            "city": "WASILLA",
            "state": "AK",
            "postal_code": "996547550",
            "telephone_number": "907-373-5950",
            "fax_number": "907-373-5954"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COTTONWOOD CREEK CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-10-09",
        "last_updated": "2023-03-07",
        "certification_date": "2020-02-14",
        "status": "A",
        "authorized_official_last_name": "BLAKE",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "907-373-5950"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "AK",
            "license": "1011473",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Mariam Corpus
• Larry Howard Correll
• Nancy Jane Correll
• Myha Cortez
• Kiela Cott
• Michael Cowan, PTA
• Jacqueline Marie Cox, MA, LPC
• Emily Kristine Crager
• Cody Craig, DPT
• Craig. R. Lowrie, LLC Dba Advanced Family Dentistry

• Internal Medicine Physician in Wasilla, AK
• Providers in Wasilla, AK by specialty
• Internal Medicine Physician in Alaska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.