Provider Demographics
NPI:1083368047
Name:KOECH, RODGERS (ARNP)
Entity Type:Individual
Prefix:
First Name:RODGERS
Middle Name:
Last Name:KOECH
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WALTER ST NE STE 110
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2541
Mailing Address - Country:US
Mailing Address - Phone:505-727-8360
Mailing Address - Fax:
Practice Address - Street 1:601 DR MARTIN LUTHER KING JR AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3619
Practice Address - Country:US
Practice Address - Phone:505-727-8360
Practice Address - Fax:505-727-8768
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM67740363LA2100X
KS5380849052363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM08009333Medicaid