Provider Demographics
NPI:1851475784
Name:KOCH, JEFFREY A (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:KOCH
Suffix:
Gender:M
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 1:380 SOUTHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-4761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1218 S BROADWAY
Practice Address - Street 2:SUITE 310
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2759
Practice Address - Country:US
Practice Address - Phone:859-219-0542
Practice Address - Fax:859-219-9433
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002481Medicaid
KY95002481Medicaid
0572146Medicare PIN