Provider Demographics
NPI:1336669217
Name:KOOCHEL, ETHAN PATRICK (DPT, PT, ATC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:PATRICK
Last Name:KOOCHEL
Suffix:
Gender:M
Credentials:DPT, PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 QUAIL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-6838
Mailing Address - Country:US
Mailing Address - Phone:620-793-0092
Mailing Address - Fax:
Practice Address - Street 1:935 E 4TH ST.
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441
Practice Address - Country:US
Practice Address - Phone:785-539-9669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-055712251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic