Provider Demographics
NPI:1740397512
Name:KOONTZ, THOMAS MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:KOONTZ
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 1:3123 RIVA RD
Mailing Address - Street 2:UNIT 615
Mailing Address - City:RIVA
Mailing Address - State:MD
Mailing Address - Zip Code:21140-7528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6900 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20307-0003
Practice Address - Country:US
Practice Address - Phone:202-782-5435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant