Provider Demographics
NPI:1073655650
Name:KOHAN, WAYNE HOWARD (DC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:HOWARD
Last Name:KOHAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15005 N 40TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4511
Mailing Address - Country:US
Mailing Address - Phone:602-374-2762
Mailing Address - Fax:
Practice Address - Street 1:15005 N 40TH LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4511
Practice Address - Country:US
Practice Address - Phone:602-374-2762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00391100111N00000X
AZ7603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJKO724575Medicare ID - Type Unspecified