Basic Information
| Provider Information | |||||||||
| NPI: | 1992240865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COHO FOOT & ANKLE, PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 10TH ST E | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 W CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884062646 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2016 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | MCKEEVER | ||||||||
| AuthorizedOfficialFirstName: | DEKKER | ||||||||
| AuthorizedOfficialMiddleName: | NOLAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3605822651 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X | 60673015 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.