Healthcare Provider Details

I. General information

NPI: 1851616791
Provider Name (Legal Business Name): JOSEPH KOO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2010
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 MANKATO AVE
WINONA MN
55987-4868
US

IV. Provider business mailing address

855 MANKATO AVE
WINONA MN
55987-4868
US

V. Phone/Fax

Practice location:
  • Phone: 507-454-3650
  • Fax:
Mailing address:
  • Phone: 507-454-3650
  • 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 TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number56356
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: