Provider Demographics
NPI:1720405145
Name:KOEHLER, THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KOEHLER
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 1:91302 N COBURG INDUSTRIAL WAY
Mailing Address - Street 2:STE 122
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408-9331
Mailing Address - Country:US
Mailing Address - Phone:208-413-8406
Mailing Address - Fax:
Practice Address - Street 1:1715 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3136
Practice Address - Country:US
Practice Address - Phone:208-413-8406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA165739363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant