Provider Demographics
NPI:1073790507
Name:KOWALCZYK, CHANDRA M (CRNA)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:M
Last Name:KOWALCZYK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CHANDRA
Other - Middle Name:
Other - Last Name:NAVARRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:MAIL CODE SJH-2
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-4910
Mailing Address - Fax:503-494-8368
Practice Address - Street 1:3181 SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7641
Practice Address - Fax:503-494-8368
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK132544207L00000X
VA0024167700367500000X
VA0001210584367500000X
OR202106428CRNA-PP367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073790507Medicaid
DC3810021701Medicaid
MD414403100Medicaid
DC3810021701Medicaid