Provider Demographics
NPI:1073843041
Name:KOETTEL, CHRISTOPHER E (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:E
Last Name:KOETTEL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3129
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:850 S ATLANTIC BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-6705
Practice Address - Country:US
Practice Address - Phone:626-872-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-109710-092163W00000X
KS556943367500000X
KS140281367500000X
CA3853367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200637580AMedicaid