Provider Demographics
NPI:1780622548
Name:MCCOY, JON T (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:T
Last Name:MCCOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34940
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1940
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:1096 GOETHALS DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3303
Practice Address - Country:US
Practice Address - Phone:509-943-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017638207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00170258OtherRR MEDICARE
OR170845Medicaid
WA1110725Medicaid
OR170845Medicaid
WA1110725Medicaid