Provider Demographics
NPI:1336128180
Name:KOCH, BRUCE EVAN (CRNA MSN)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:EVAN
Last Name:KOCH
Suffix:
Gender:M
Credentials:CRNA MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5633 N LIDGERWOOD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208
Mailing Address - Country:US
Mailing Address - Phone:509-482-0111
Mailing Address - Fax:
Practice Address - Street 1:5633 N LIDGERWOOD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:509-482-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007302367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARN00163452OtherSTATE LICENSE
CARN3329700Medicaid
WAAP30007302OtherSTATE LICENSE
CARN3329700Medicaid
CAR38117Medicare UPIN