Provider Demographics
NPI:1568421758
Name:KOEHLER, KEVIN J (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:KOEHLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 W 119TH ST STE 430
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3721
Mailing Address - Country:US
Mailing Address - Phone:816-523-7088
Mailing Address - Fax:816-523-5747
Practice Address - Street 1:5701 W 119TH ST
Practice Address - Street 2:STE 120
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-3721
Practice Address - Country:US
Practice Address - Phone:913-906-0833
Practice Address - Fax:913-906-0829
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009025417363A00000X
KS0426923363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200257580AMedicaid
MOW82000002Medicare PIN
KS426722Medicare ID - Type Unspecified
KSP34404Medicare UPIN