Healthcare Provider Details

I. General information

NPI: 1598571200
Provider Name (Legal Business Name): MARANDA NAOMI KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E MAIN ST STE B
PAYSON AZ
85541-5488
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-468-8610
  • Fax: 928-468-8605
Mailing address:
  • Phone: 928-522-9879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11323
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: