Healthcare Provider Details

I. General information

NPI: 1003423237
Provider Name (Legal Business Name): OCHUKO ANDREW OGHOR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

PO BOX 4095
KALAMAZOO MI
49003-4095
US

V. Phone/Fax

Practice location:
  • Phone: 239-341-7654
  • Fax:
Mailing address:
  • Phone: 269-345-8618
  • Fax: 269-345-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704314356
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: