Provider Demographics
NPI:1275609364
Name:KOIVUNEN, JON ANTHONY (MD)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:ANTHONY
Last Name:KOIVUNEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 W SWANSON AVENUE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6853
Mailing Address - Country:US
Mailing Address - Phone:907-376-5228
Mailing Address - Fax:907-376-8126
Practice Address - Street 1:351 W SWANSON AVENUE
Practice Address - Street 2:SUITE 4
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6853
Practice Address - Country:US
Practice Address - Phone:907-376-5228
Practice Address - Fax:907-376-8126
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD1355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1355Medicaid
AK043921OtherFAA
AKMD1355Medicaid
0000BHGZRMedicare ID - Type Unspecified