Provider Demographics
NPI:1811019821
Name:KOEHLER, JOSHUA JACK (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:JACK
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 1:950B N WYOMISSING BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1783
Mailing Address - Country:US
Mailing Address - Phone:610-898-2491
Mailing Address - Fax:
Practice Address - Street 1:950B N WYOMISSING BLVD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1783
Practice Address - Country:US
Practice Address - Phone:610-898-2491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP52178Medicare UPIN