Provider Demographics
NPI:1891134680
Name:KOCH, NATHAN DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:DAVID
Last Name:KOCH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 WOODTHRUSH RD
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-2834
Mailing Address - Country:US
Mailing Address - Phone:918-805-9042
Mailing Address - Fax:
Practice Address - Street 1:1601 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-4409
Practice Address - Country:US
Practice Address - Phone:580-760-0927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2131225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant