Provider Demographics
NPI:1033689666
Name:KOCH, COLTON A
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:A
Last Name:KOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17550 K16 HWY
Mailing Address - Street 2:
Mailing Address - City:MCLOUTH
Mailing Address - State:KS
Mailing Address - Zip Code:66054
Mailing Address - Country:US
Mailing Address - Phone:913-689-9650
Mailing Address - Fax:
Practice Address - Street 1:17550 K16 HWY
Practice Address - Street 2:
Practice Address - City:MCLOUTH
Practice Address - State:KS
Practice Address - Zip Code:66054
Practice Address - Country:US
Practice Address - Phone:913-689-9650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSXSB874710819OtherBLUECROSS BLUESHIELD OF KANSAS