Healthcare Provider Details

I. General information

NPI: 1982939302
Provider Name (Legal Business Name): MARSHALL ROY KOON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2009
Last Update Date: 10/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 US HIGHWAY 18
APPLE VALLEY CA
92307-2206
US

IV. Provider business mailing address

18300 US HIGHWAY 18
APPLE VALLEY CA
92307-2206
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-2311
  • Fax:
Mailing address:
  • Phone: 760-242-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA20578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: