Healthcare Provider Details

I. General information

NPI: 1003549056
Provider Name (Legal Business Name): PIET KOENE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 N 7TH AVE
SHELDON IA
51201-1235
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 712-203-9614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberF07220307
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA170187
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: