Healthcare Provider Details

I. General information

NPI: 1326416140
Provider Name (Legal Business Name): PETER KOENIG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E 104TH AVE STE 115
THORNTON CO
80233-4402
US

IV. Provider business mailing address

2200 E 104TH AVE STE 115
THORNTON CO
80233-4402
US

V. Phone/Fax

Practice location:
  • Phone: 303-452-2766
  • Fax: 303-252-8694
Mailing address:
  • Phone: 303-452-2766
  • Fax: 303-252-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA0004394
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: