Healthcare Provider Details

I. General information

NPI: 1982890455
Provider Name (Legal Business Name): PATRICIA CLAIRE KOONCE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 06/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 BUSINESS LOOP 70 W
COLUMBIA MO
65203-3248
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-0033
  • Fax: 573-884-5226
Mailing address:
  • Phone: 573-882-8612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR1D69
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: