Provider Demographics
NPI:1639643836
Name:KOCH, ALEXANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 SHANNON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6343
Mailing Address - Country:US
Mailing Address - Phone:919-946-8124
Mailing Address - Fax:
Practice Address - Street 1:3604 SHANNON RD STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6343
Practice Address - Country:US
Practice Address - Phone:919-403-2122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08780363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant