Provider Demographics
NPI:1174851695
Name:KOFCHOCK, NITA
Entity Type:Individual
Prefix:
First Name:NITA
Middle Name:
Last Name:KOFCHOCK
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 1:202 E EARLL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2647
Mailing Address - Country:US
Mailing Address - Phone:602-808-2800
Mailing Address - Fax:602-808-2799
Practice Address - Street 1:2802 E DISTRICT ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-2081
Practice Address - Country:US
Practice Address - Phone:520-301-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201710096NP-PP2084P0800X
AZAP8509363LP0808X
WAAP60291694363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP60291694OtherWASHINGTON STATE LICENSE
AZ094362Medicaid