Healthcare Provider Details

I. General information

NPI: 1770603979
Provider Name (Legal Business Name): KIRK KOYAMA RN, PHN, MSN, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 191, HOSPITAL DR.
CHINLE AZ
86503-0220
US

IV. Provider business mailing address

PO BOX 220
CHINLE AZ
86503-0220
US

V. Phone/Fax

Practice location:
  • Phone: 928-674-7184
  • Fax:
Mailing address:
  • Phone: 928-674-7184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number511644
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number2218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: