Provider Demographics
NPI:1558337493
Name:KOERNER, MICHAEL K (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:KOERNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2326 RUCKER AVENUE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2723
Mailing Address - Country:US
Mailing Address - Phone:425-259-5121
Mailing Address - Fax:425-339-8517
Practice Address - Street 1:2326 RUCKER AVENUE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-2723
Practice Address - Country:US
Practice Address - Phone:425-259-5121
Practice Address - Fax:425-339-8517
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00024979204D00000X
WAMD000249792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1054626Medicaid
A06364Medicare UPIN
WAA06364Medicare UPIN
WA1054626Medicaid