Healthcare Provider Details

I. General information

NPI: 1861716805
Provider Name (Legal Business Name): SHIRLEY SANDY KOON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2010
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ALHAMBRA BLVD SUITE 220
SACRAMENTO CA
95816-5238
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-731-7925
  • Fax: 916-731-7975
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOP60389702
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A14866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: