Provider Demographics
NPI:1912978099
Name:KORDIYAK, STEPHEN M (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:KORDIYAK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4257
Mailing Address - Country:US
Mailing Address - Phone:262-787-4026
Mailing Address - Fax:262-782-6040
Practice Address - Street 1:115 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2711
Practice Address - Country:US
Practice Address - Phone:715-623-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI113499367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
044383OtherCRNA RECERTIFICATION CARD
WI43314500Medicaid
007000492Medicare PIN
044383OtherCRNA RECERTIFICATION CARD
R39689Medicare UPIN
WI0007-43110Medicare ID - Type UnspecifiedPROVIDER NUMBER