Provider Demographics
NPI:1295138972
Name:KODIAK ANESTHESIA PC
Entity type:Organization
Organization Name:KODIAK ANESTHESIA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHYNOWETH
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:4850 CHINOOK TRL
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-5201
Practice Address - Country:US
Practice Address - Phone:307-473-8173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7192A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty