Provider Demographics
NPI:1912908468
Name:KOOGLER, MARY C (FNP ONC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:KOOGLER
Suffix:
Gender:F
Credentials:FNP ONC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SEVENTH ST
Mailing Address - Street 2:
Mailing Address - City:GROTTOES
Mailing Address - State:VA
Mailing Address - Zip Code:24441
Mailing Address - Country:US
Mailing Address - Phone:540-249-5901
Mailing Address - Fax:540-249-5902
Practice Address - Street 1:100 7TH STREET
Practice Address - Street 2:
Practice Address - City:GROTTOES
Practice Address - State:VA
Practice Address - Zip Code:24441-0489
Practice Address - Country:US
Practice Address - Phone:540-249-5901
Practice Address - Fax:540-249-5902
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024-120331363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007795050Medicaid
270565OtherANTHEM
VA007795050Medicaid
VA001368H96Medicare ID - Type Unspecified