Provider Demographics
NPI:1497908487
Name:KOCH, TARA ANN (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ANN
Last Name:KOCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5523
Mailing Address - Country:US
Mailing Address - Phone:917-710-3397
Mailing Address - Fax:
Practice Address - Street 1:800 WOODBURY RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2503
Practice Address - Country:US
Practice Address - Phone:516-496-9400
Practice Address - Fax:516-496-9212
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant