Provider Demographics
NPI:1104825728
Name:KOEHN, NERISSA (MD)
Entity type:Individual
Prefix:DR
First Name:NERISSA
Middle Name:
Last Name:KOEHN
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 7609
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7609
Mailing Address - Country:US
Mailing Address - Phone:406-721-5600
Mailing Address - Fax:
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-721-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H95743Medicare UPIN