Provider Demographics
NPI:1982890455
Name:KOONCE, PATRICIA CLAIRE (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:CLAIRE
Last Name:KOONCE
Suffix:
Gender:F
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 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-8612
Mailing Address - Fax:
Practice Address - Street 1:315 BUSINESS LOOP 70 W
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3248
Practice Address - Country:US
Practice Address - Phone:573-884-0033
Practice Address - Fax:573-884-5226
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1D69208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206971319Medicaid
A25757Medicare UPIN
MO042535236Medicare PIN