Provider Demographics
NPI:1639757255
Name:KOONOOKA, BARTON D (CHA-T)
Entity Type:Individual
Prefix:
First Name:BARTON
Middle Name:D
Last Name:KOONOOKA
Suffix:
Gender:M
Credentials:CHA-T
Other - Prefix:
Other - First Name:BARTON
Other - Middle Name:D
Other - Last Name:KOONOOKA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHA-T
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:GAMBELL
Mailing Address - State:AK
Mailing Address - Zip Code:99742-0190
Mailing Address - Country:US
Mailing Address - Phone:907-985-5012
Mailing Address - Fax:
Practice Address - Street 1:190 BOWHEAD WAY
Practice Address - Street 2:
Practice Address - City:GAMBELL
Practice Address - State:AK
Practice Address - Zip Code:99742-0190
Practice Address - Country:US
Practice Address - Phone:907-985-5012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA-TOtherCHA-T