Provider Demographics
NPI:1982950978
Name:WITCZAK, CHESTER JOSEPH (CRNA)
Entity Type:Individual
Prefix:
First Name:CHESTER
Middle Name:JOSEPH
Last Name:WITCZAK
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 1:610 S BAILEY ST
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6330
Mailing Address - Country:US
Mailing Address - Phone:717-968-7149
Mailing Address - Fax:907-745-0200
Practice Address - Street 1:2500 S WOODWORTH LOOP
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8984
Practice Address - Country:US
Practice Address - Phone:717-968-7149
Practice Address - Fax:907-745-0200
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPENDINGMedicaid