Healthcare Provider Details

I. General information

NPI: 1992240865
Provider Name (Legal Business Name): COHO FOOT & ANKLE, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2016
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W CEDAR ST
SEQUIM WA
98382
US

IV. Provider business mailing address

400 10TH ST E
WACONIA MN
55387-4552
US

V. Phone/Fax

Practice location:
  • Phone: 888-406-2646
  • Fax: 952-442-3620
Mailing address:
  • Phone: 952-442-9770
  • Fax: 952-442-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number60673015
License Number StateWA

VIII. Authorized Official

Name: DR. DEKKER NOLAN MCKEEVER
Title or Position: PRESIDENT
Credential: DPM
Phone: 360-582-2651