Provider Demographics
NPI:1295741239
Name:KOCH, TRACEY (FNP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:KOCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N SECOND AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1565
Mailing Address - Country:US
Mailing Address - Phone:208-265-2242
Mailing Address - Fax:208-265-8214
Practice Address - Street 1:420 N SECOND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1565
Practice Address - Country:US
Practice Address - Phone:208-265-2242
Practice Address - Fax:208-265-8214
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP461A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806191100Medicaid
ID1343429Medicare ID - Type Unspecified
ID806191100Medicaid