Provider Demographics
NPI:1891213336
Name:KOCH, CHANTELLE TANYA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHANTELLE
Middle Name:TANYA
Last Name:KOCH
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 MICHIGAN ST NE STE 5500
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2565
Practice Address - Country:US
Practice Address - Phone:616-267-8540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601008328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant