Basic Information
| Provider Information | |||||||||
| NPI: | 1700483278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOCH | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 W SUNSET DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078567021 | ||||||||
| FaxNumber: | 3078565546 | ||||||||
| Practice Location | |||||||||
| Address1: | 8168 HIGHWAY 789 | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825202953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073325240 | ||||||||
| FaxNumber: | 3073325241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2013 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.