Provider Demographics
NPI:1710087689
Name:KODIAK ANESTHESIA PC
Entity Type:Organization
Organization Name:KODIAK ANESTHESIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHYNOWETH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:307-473-8173
Mailing Address - Street 1:4850 CHINOOK TRL
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-5201
Mailing Address - Country:US
Mailing Address - Phone:307-473-8173
Mailing Address - Fax:
Practice Address - Street 1:111 W 2ND ST
Practice Address - Street 2:SUITE 415
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2454
Practice Address - Country:US
Practice Address - Phone:307-237-5848
Practice Address - Fax:307-237-5848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7192A170100000X
207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty