Healthcare Provider Details

I. General information

NPI: 1548261985
Provider Name (Legal Business Name): SAMUEL WILLIAM KOCHANSKY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 MASRHEAD ST NE SUITE 120
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

12231 ACADEMY RD NE #301-229
ALBUQUERQUE NM
87111-7236
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-7729
  • Fax:
Mailing address:
  • Phone: 512-415-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA00897
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: