MEDICARE: DR. NERISSA KOEHN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	12747	MT

General Provider Information

NPI Number	:	1104825728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NERISSA KOEHN MD

Provider Business Mailing Address
First Line	:	PO BOX 7609
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59807-7609
Country	:	US
Telephone Number	:	406-721-5600
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 W BROADWAY ST
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59802-4008
Country	:	US
Telephone Number	:	406-721-5600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	04/18/2022

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