Provider Demographics
NPI:1649642034
Name:KOVACHEVICH, CHRISTA J (ARNP, CPNP-PC)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:J
Last Name:KOVACHEVICH
Suffix:
Gender:F
Credentials:ARNP, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2076 PAINTED SKY RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-9196
Mailing Address - Country:US
Mailing Address - Phone:321-313-3595
Mailing Address - Fax:
Practice Address - Street 1:1307 CROOK AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5412
Practice Address - Country:US
Practice Address - Phone:321-313-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9390419363LP0200X
WY43135363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016218600Medicaid