Basic Information
| Provider Information | |||||||||
| NPI: | 1790711109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHASTEEN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 SUNSET DR | ||||||||
| Address2: | P.O. BOX 3290 | ||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419638421 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419638421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD23491 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9001CHA | 01 | OR | CHAMPUS | OTHER | 297575 | 05 | OR | MEDICAID |