Basic Information
| Provider Information | |||||||||
| NPI: | 1326524414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOICH | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | ESTHER | ||||||||
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| Credential: | MS, LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1414 JULIET AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551052565 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8100 W 78TH ST | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2018 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 8244 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.