Provider Demographics
NPI:1922401066
Name:KOCH, JASON R (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
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 1:7220 MOUNT RUSHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8754
Mailing Address - Country:US
Mailing Address - Phone:605-737-9144
Mailing Address - Fax:
Practice Address - Street 1:7220 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702
Practice Address - Country:US
Practice Address - Phone:605-341-1414
Practice Address - Fax:605-341-7062
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant