Provider Demographics
NPI:1255304317
Name:KOUKLIS, NORMA V (MD)
Entity Type:Individual
Prefix:
First Name:NORMA
Middle Name:V
Last Name:KOUKLIS
Suffix:
Gender:F
Credentials:MD
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 98886
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98496-8886
Mailing Address - Country:US
Mailing Address - Phone:253-589-6484
Mailing Address - Fax:253-984-1079
Practice Address - Street 1:4901 108TH ST SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98499-3724
Practice Address - Country:US
Practice Address - Phone:253-589-6484
Practice Address - Fax:253-984-1079
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00011925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1472703Medicaid
WAG8809451Medicare PIN
WAG8857351Medicare PIN
WA1472703Medicaid