Provider Demographics
NPI:1821676669
Name:KOCH, ANTHONY (PMHNP)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6923 GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8653
Mailing Address - Country:US
Mailing Address - Phone:330-398-1132
Mailing Address - Fax:
Practice Address - Street 1:2180 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4558
Practice Address - Country:US
Practice Address - Phone:805-781-4768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61287688163WP0808X
OHRN.445266163W00000X
OH0029697363LP0808X
WAAP61289252363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse