Provider Demographics
NPI:1629166434
Name:KOEHNE, THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KOEHNE
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 1:697 MAITLAND AVENUE
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701
Mailing Address - Country:US
Mailing Address - Phone:407-539-2111
Mailing Address - Fax:407-539-1211
Practice Address - Street 1:697 MAITLAND AVENUE
Practice Address - Street 2:SUITE 1002
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701
Practice Address - Country:US
Practice Address - Phone:407-539-2111
Practice Address - Fax:407-539-1211
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0003198363AS0400X
FLPA3198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL972885OtherP.A.CERTIFICATE NUMBER
FL970006599OtherRR MC PROVIDER NUMBER
FL290428400Medicaid
FLPA0003198OtherP.A.LICENSE NUMBER
FL290428400Medicaid