Provider Demographics
NPI:1710082508
Name:KOIRTH, CANDACE D (ARNP)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:D
Last Name:KOIRTH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 COMMODORE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-2901
Mailing Address - Country:US
Mailing Address - Phone:888-900-7762
Mailing Address - Fax:620-450-1371
Practice Address - Street 1:124 COMMODORE ST
Practice Address - Street 2:SUITE A
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2901
Practice Address - Country:US
Practice Address - Phone:888-900-7762
Practice Address - Fax:620-450-1371
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45129363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1286700009OtherDMERC REGION 1
12867010010OtherDMERC REGION 1
1286700002OtherDMERC REGION 1
1286700007OtherDMERC REGION 1
1286700008OtherDMERC REGION 1
1286700011OtherDMERC REGION 1
KS100416640AMedicaid
1286700015OtherDMERC REGION 1
KS500023194OtherRAIL ROAD MEDICARE
1286700004OtherDMERC REGION 1
1286700005OtherDMERC REGION 1
1286700003OtherDMERC REGION 1
1286700012OtherDMERC REGION 1
1286700006OtherDMERC REGION 1
1286700013OtherDMERC REGION 1
1286700006OtherDMERC REGION 1
KS500023194OtherRAIL ROAD MEDICARE