Provider Demographics
NPI:1093725905
Name:KOCH, LISA ANNE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNE
Last Name:KOCH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:848 N SAINT FRANCIS ST STE 2945
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3856
Mailing Address - Country:US
Mailing Address - Phone:316-268-5591
Mailing Address - Fax:316-291-7890
Practice Address - Street 1:848 N SAINT FRANCIS ST STE 2945
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3856
Practice Address - Country:US
Practice Address - Phone:316-268-5591
Practice Address - Fax:316-291-7890
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-45853163WE0003X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287340AMedicaid
KS200402630JMedicaid
OK200287340AMedicaid
KS200402630JMedicaid