Provider Demographics
NPI:1306138003
Name:KOONZ, TONYA ASHLEY (PA-C)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:ASHLEY
Last Name:KOONZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TONYA
Other - Middle Name:ASHLEY
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4381 SOMERSET DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-4626
Mailing Address - Country:US
Mailing Address - Phone:678-386-8756
Mailing Address - Fax:
Practice Address - Street 1:3333 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:678-386-8756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109689AMedicaid
GA202I978495Medicare PIN