Provider Demographics
NPI:1093967887
Name:KOEHLER, JAYNE ALYSSA (PA-C)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:ALYSSA
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 POWELL DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9203
Practice Address - Country:US
Practice Address - Phone:803-957-8400
Practice Address - Fax:803-957-1939
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL1353363AM0700X
SC1353363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1080454OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS