Healthcare Provider Details

I. General information

NPI: 1740671148
Provider Name (Legal Business Name): ALEX YUSHAUN KOO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2015
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-1000
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-1000
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone: 253-968-2997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD60859647
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number29450
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: