Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | R2085 | AR |
NPI | 1124077078 |
---|---|
Provider Name | Dr. Laura Jane Koehn |
First Address | Fayetteville, AR 72703-2807 |
Second Address | Fayetteville, AR 72703-2807 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2006 |
Last Update Date | 12/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12198000000 | QUALCHOICE PROV # (01) | AR |
325026 | HEALTHLINK PROV # (01) | AR |
52963 | BCBS PROV # (01) | AR |
D04713 | (02) | AR |