Provider Demographics
NPI:1992240865
Name:COHO FOOT & ANKLE, PS
Entity type:Organization
Organization Name:COHO FOOT & ANKLE, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEKKER
Authorized Official - Middle Name:NOLAN
Authorized Official - Last Name:MCKEEVER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-582-2651
Mailing Address - Street 1:400 10TH ST E
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3620
Practice Address - Street 1:103 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382
Practice Address - Country:US
Practice Address - Phone:888-406-2646
Practice Address - Fax:952-442-3620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0103X
WA60673015261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty