Provider Demographics
NPI:1073572798
Name:CHENNAULT, REGINA SUTTON (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINA
Middle Name:SUTTON
Last Name:CHENNAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:REGINA
Other - Middle Name:CHRISTINE
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 111045
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-1045
Mailing Address - Country:US
Mailing Address - Phone:907-222-6888
Mailing Address - Fax:907-222-6884
Practice Address - Street 1:2751 DEBARR RD
Practice Address - Street 2:SUITE 280A
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2952
Practice Address - Country:US
Practice Address - Phone:907-222-6888
Practice Address - Fax:907-222-6884
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5170208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD80853Medicaid
F91164Medicare UPIN
AKK152723Medicare ID - Type Unspecified