Healthcare Provider Details

I. General information

NPI: 1942278130
Provider Name (Legal Business Name): LARRY J KOTEWA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W WHITEHALL CT
PEORIA IL
61614-3032
US

IV. Provider business mailing address

124 W WHITEHALL CT
PEORIA IL
61614-3032
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-2607
  • Fax: 309-683-1003
Mailing address:
  • Phone: 309-691-2607
  • Fax: 309-683-1003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: