Provider Demographics
NPI:1689678914
Name:KOENIG, THOMAS A (SAC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:KOENIG
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:A
Other - Last Name:KOENIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OPA-C
Mailing Address - Street 1:560 SOUTH LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3454
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:560 SOUTH LOOP RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3454
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-301-0655
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02-296363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCSA98601OtherCHOICE CARE PROVIDER ID