Provider Demographics
NPI:1073199873
Name:KOEHLER, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:KOEHLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-2231
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-5705
Practice Address - Country:US
Practice Address - Phone:505-272-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program