Healthcare Provider Details

I. General information

NPI: 1871294553
Provider Name (Legal Business Name): AARON V KOEHLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ONE MILE RD
DEXTER MO
63841-1000
US

IV. Provider business mailing address

649 MESA LN
JACKSON MO
63755-3795
US

V. Phone/Fax

Practice location:
  • Phone: 573-624-5566
  • Fax:
Mailing address:
  • Phone: 573-579-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2023009296
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: