Provider Demographics
NPI:1356326631
Name:KOCK, CHARLES L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:KOCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:CHARLES
Other - Middle Name:LEWIS
Other - Last Name:KOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN, ASSISTANT
Mailing Address - Street 1:201 DENNING DR.
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360
Mailing Address - Country:US
Mailing Address - Phone:985-855-4829
Mailing Address - Fax:
Practice Address - Street 1:201 DENNING DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-3977
Practice Address - Country:US
Practice Address - Phone:985-855-4829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10076363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA970006535OtherRR MEDICARE
LA1624845Medicaid
LA970006535OtherRR MEDICARE
LA51763Medicare PIN