Provider Demographics
NPI:1861716805
Name:KOON, SHIRLEY SANDY (DO)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:SANDY
Last Name:KOON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:1201 ALHAMBRA BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5238
Practice Address - Country:US
Practice Address - Phone:916-731-7925
Practice Address - Fax:916-731-7975
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP60389702207R00000X
CA20A14866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01230600OtherRAILROAD MDC
WA8922791Medicare PIN
WA8922790Medicare PIN