Healthcare Provider Details

I. General information

NPI: 1932861879
Provider Name (Legal Business Name): KACI LYNN KOCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 04/26/2024
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14815 N DEL WEBB BLVD
SUN CITY AZ
85351-2145
US

IV. Provider business mailing address

14815 N DEL WEBB BLVD
SUN CITY AZ
85351-2145
US

V. Phone/Fax

Practice location:
  • Phone: 623-277-0759
  • Fax:
Mailing address:
  • Phone: 623-277-0759
  • Fax: 623-200-5519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8805
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: