MEDICARE: DIANA R KOON NP

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	363LF0000X	Family Nurse Practitioner	563192	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205009735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA R KOON NP

Provider Business Mailing Address
First Line	:	1675 REPUBLIC PKWY STE 100
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150-6902
Country	:	US
Telephone Number	:	972-620-9111
Fax Number	:	972-620-9187

Provider Business Practice Location Address
First Line	:	1675 REPUBLIC PKWY STE 100
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150-6902
Country	:	US
Telephone Number	:	972-620-9111
Fax Number	:	972-620-9187

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

Provider Enumeration Date	:	04/04/2008
Last Update Date	:	04/29/2011

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Directions to “ DIANA R KOON NP” Practice Location

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