Healthcare Provider Details

I. General information

NPI: 1720405145
Provider Name (Legal Business Name): THOMAS KOEHLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 E 12TH ST
THE DALLES OR
97058-3136
US

IV. Provider business mailing address

91302 N COBURG INDUSTRIAL WAY STE 122
COBURG OR
97408-9331
US

V. Phone/Fax

Practice location:
  • Phone: 208-413-8406
  • Fax:
Mailing address:
  • Phone: 208-413-8406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA165739
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: