Healthcare Provider Details

I. General information

NPI: 1750455150
Provider Name (Legal Business Name): DANITA NEVITT KOEHLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 GAFFNEY RD
FT WAINWRIGHT AK
99703-5001
US

IV. Provider business mailing address

HC 62 BOX 5217
DELTA JUNCTION AK
99737-9601
US

V. Phone/Fax

Practice location:
  • Phone: 907-361-5345
  • Fax:
Mailing address:
  • Phone: 907-323-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3184
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3184
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11272
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: