Provider Demographics
NPI:1417829219
Name:KINISU, EDWIN (MBA)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:
Last Name:KINISU
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 RUSTY ALLEN PL
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-4879
Mailing Address - Country:US
Mailing Address - Phone:907-227-9688
Mailing Address - Fax:
Practice Address - Street 1:145 RUSTY ALLEN PL
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-4879
Practice Address - Country:US
Practice Address - Phone:907-227-9688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator