Provider Demographics
NPI:1902058308
Name:KOEHLER, TIMOTHY ADAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ADAM
Last Name:KOEHLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-6690
Mailing Address - Country:US
Mailing Address - Phone:910-893-4111
Mailing Address - Fax:910-893-9850
Practice Address - Street 1:4450 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-3612
Practice Address - Country:US
Practice Address - Phone:919-772-3154
Practice Address - Fax:910-893-9850
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001001539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant