Healthcare Provider Details

I. General information

NPI: 1912978099
Provider Name (Legal Business Name): STEPHEN M. KORDIYAK C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E 5TH AVE
ANTIGO WI
54409-2711
US

IV. Provider business mailing address

225 S EXECUTIVE DR
BROOKFIELD WI
53005-4257
US

V. Phone/Fax

Practice location:
  • Phone: 715-623-2331
  • Fax:
Mailing address:
  • Phone: 262-787-4026
  • Fax: 262-782-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number113499
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: