Provider Demographics
NPI:1891926564
Name:KVASNIKOFF, ELIAS E (CHA III C)
Entity Type:Individual
Prefix:MR
First Name:ELIAS
Middle Name:E
Last Name:KVASNIKOFF
Suffix:
Gender:M
Credentials:CHA III C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8023
Mailing Address - Street 2:
Mailing Address - City:NANWALEK
Mailing Address - State:AK
Mailing Address - Zip Code:99603-6623
Mailing Address - Country:US
Mailing Address - Phone:907-281-2250
Mailing Address - Fax:907-281-2244
Practice Address - Street 1:64834 NIKITA STREET
Practice Address - Street 2:
Practice Address - City:NANWALEK
Practice Address - State:AK
Practice Address - Zip Code:99603-8023
Practice Address - Country:US
Practice Address - Phone:907-281-2250
Practice Address - Fax:907-281-2244
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDH0191Medicaid