Provider Demographics
NPI:1760713895
Name:KOEHLER, CHELSEY R (PA)
Entity Type:Individual
Prefix:
First Name:CHELSEY
Middle Name:R
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHELSEY
Other - Middle Name:R
Other - Last Name:WERNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:444 W FORT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4535
Mailing Address - Country:US
Mailing Address - Phone:208-422-1018
Mailing Address - Fax:
Practice Address - Street 1:444 W FORT ST FL 2
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4535
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-29
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200636660BMedicaid
KS003719081Medicare Oscar/Certification