Provider Demographics
NPI:1780564435
Name:KOEHL, MARK (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KOEHL
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Gender:M
Credentials:PA
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Mailing Address - Street 1:1721 MAGNAVOX WAY STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1537
Mailing Address - Country:US
Mailing Address - Phone:260-748-3650
Mailing Address - Fax:260-748-3651
Practice Address - Street 1:1721 MAGNAVOX WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1537
Practice Address - Country:US
Practice Address - Phone:260-748-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant