Provider Demographics
NPI:1083097133
Name:KOCH, MIKAELA (PA-C)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 WHITE MOUNTAIN HWY STE A
Mailing Address - Street 2:
Mailing Address - City:SANBORNVILLE
Mailing Address - State:NH
Mailing Address - Zip Code:03872-4429
Mailing Address - Country:US
Mailing Address - Phone:603-522-0186
Mailing Address - Fax:603-522-3457
Practice Address - Street 1:3827 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-3339
Practice Address - Country:US
Practice Address - Phone:303-500-1518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057649363A00000X
COPA.0006670363A00000X
NH1410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant