Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 43309 | MN |
Y | 207QS0010X | Family Doctor - Sports Medicine | 43309 | MN |
NPI | 1033173414 |
---|---|
Provider Name | Scott Mark Koehler |
First Address | Minneapolis, MN 55407-1321 |
Second Address | Northfield, MN 55057-3081 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2006 |
Last Update Date | 09/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
482493800 | (05) | MN |
H22914 | (02) |