Provider Demographics
NPI:1598837643
Name:KOEHLER, JEFFREY A (PA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:KOEHLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 IRVING AVE
Mailing Address - Street 2:5 WEST TOWER ROOM 5632
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1687
Mailing Address - Country:US
Mailing Address - Phone:315-470-7111
Mailing Address - Fax:
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:5 WEST TOWER ROOM 5632
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1687
Practice Address - Country:US
Practice Address - Phone:315-470-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004183-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970023623Medicare PIN
W70052Medicare PIN
S33685Medicare UPIN