Provider Demographics
NPI:1457317422
Name:KOENIG, MICHAEL W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:KOENIG
Suffix:
Gender:M
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 W HIGH ST STE 3
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1681
Practice Address - Country:US
Practice Address - Phone:419-636-4517
Practice Address - Fax:419-636-6438
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103933363A00000X
OH50.003014RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD1248OtherMEDCOST
NC2759426Medicare ID - Type Unspecified
OH9308738Medicare PIN
NCD1248OtherMEDCOST
OH9123072Medicare PIN