Provider Demographics
NPI:1083011662
Name:CHIKONKA, MICHELO ANDREW (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELO
Middle Name:ANDREW
Last Name:CHIKONKA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:ANDREW
Other - Middle Name:
Other - Last Name:CHIKONKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-577-4200
Practice Address - Fax:317-577-4200
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28160736A367500000X, 367500000X
IL209015469367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430F21OtherMEDICARE PTAN
IN201272920Medicaid
INQ00642896OtherRAILROAD PTAN
INP01714288Medicare PIN