Healthcare Provider Details

I. General information

NPI: 1659971034
Provider Name (Legal Business Name): ETHAN JOHN CHUPKA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 16TH ST
PUEBLO CO
81003-2745
US

IV. Provider business mailing address

400 W 16TH ST
PUEBLO CO
81003-2745
US

V. Phone/Fax

Practice location:
  • Phone: 719-584-4045
  • Fax: 719-542-0809
Mailing address:
  • Phone: 719-584-4045
  • Fax: 719-542-0809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.1000360-CRNA
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704315820
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704315820
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: