Provider Demographics
NPI:1982378493
Name:KOCHANIK, DENNIS LEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:LEE
Last Name:KOCHANIK
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11431 N PORT WASHINGTON RD STE 101B
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3463
Mailing Address - Country:US
Mailing Address - Phone:267-699-8834
Mailing Address - Fax:
Practice Address - Street 1:11431 N PORT WASHINGTON RD STE 101B
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3463
Practice Address - Country:US
Practice Address - Phone:267-699-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-07
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI245684-30163W00000X
CA95019168363LP0808X
KS5380327022363LP0808X
HIAPRN-3414-0363LP0808X
WI11305-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100190462Medicaid