Basic Information
| Provider Information | |||||||||
| NPI: | 1851310791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOENIG | ||||||||
| FirstName: | LE ROY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP-C, GNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8843 E BUCKBOARD RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857499658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | 5206294783 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 S 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857230001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | 5206294783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP7102 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | RN035147 | AZ | N | Nursing Service Providers | Registered Nurse | 363LA2100X | AP7102 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | 267 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 13 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.