Provider Demographics
NPI:1043463680
Name:KOCH, NICOLE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 MUSGROVE RD 3105
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-5202
Mailing Address - Country:US
Mailing Address - Phone:301-989-0193
Mailing Address - Fax:301-879-2325
Practice Address - Street 1:10400 CONNECTICUT AVE
Practice Address - Street 2:STE 606
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-3910
Practice Address - Country:US
Practice Address - Phone:301-942-2212
Practice Address - Fax:301-917-6501
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003886363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical