Provider Demographics
NPI:1467943738
Name:KOCH, TANNER ALLEN (LAT/ATC)
Entity Type:Individual
Prefix:MR
First Name:TANNER
Middle Name:ALLEN
Last Name:KOCH
Suffix:
Gender:M
Credentials:LAT/ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 BIRDIE LN
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-6740
Mailing Address - Country:US
Mailing Address - Phone:214-476-2455
Mailing Address - Fax:
Practice Address - Street 1:2810 BIRDIE LN
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-6740
Practice Address - Country:US
Practice Address - Phone:214-476-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer