Healthcare Provider Details

I. General information

NPI: 1629166434
Provider Name (Legal Business Name): THOMAS KOEHNE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

697 MAITLAND AVENUE SUITE 1002
ALTAMONTE SPRINGS FL
32701
US

IV. Provider business mailing address

697 MAITLAND AVENUE SUITE 1002
ALTAMONTE SPRINGS FL
32701
US

V. Phone/Fax

Practice location:
  • Phone: 407-539-2111
  • Fax: 407-539-1211
Mailing address:
  • Phone: 407-539-2111
  • Fax: 407-539-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA0003198
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3198
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: