Provider Demographics
NPI:1750162780
Name:KOCH, NICHOLAS BRENT (AGPCNP-BC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:BRENT
Last Name:KOCH
Suffix:
Gender:M
Credentials:AGPCNP-BC
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:150 E HURON ST STE 1101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2948
Mailing Address - Country:US
Mailing Address - Phone:312-741-8554
Mailing Address - Fax:312-216-1779
Practice Address - Street 1:150 E HURON ST STE 1101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2948
Practice Address - Country:US
Practice Address - Phone:312-741-8554
Practice Address - Fax:312-216-1779
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209.028387363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology