Provider Demographics
NPI:1669497095
Name:KOKE, LAURYN M (PT)
Entity Type:Individual
Prefix:
First Name:LAURYN
Middle Name:M
Last Name:KOKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BUTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4805
Mailing Address - Country:US
Mailing Address - Phone:631-905-2031
Mailing Address - Fax:631-543-2856
Practice Address - Street 1:6144 ROUTE 25A
Practice Address - Street 2:BLDG C
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2018
Practice Address - Country:US
Practice Address - Phone:631-929-3277
Practice Address - Fax:632-929-3304
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022750OtherPHYSICAL THERAPY LICENSE
NYQN6031Medicare ID - Type Unspecified