Healthcare Provider Details

I. General information

NPI: 1750162780
Provider Name (Legal Business Name): NICHOLAS BRENT KOCH AGPCNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2023
Last Update Date: 11/23/2024
Certification Date: 11/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E HURON ST STE 1101
CHICAGO IL
60611-2948
US

IV. Provider business mailing address

150 E HURON ST STE 1101
CHICAGO IL
60611-2948
US

V. Phone/Fax

Practice location:
  • Phone: 312-741-8554
  • Fax: 312-216-1779
Mailing address:
  • Phone: 312-741-8554
  • Fax: 312-216-1779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.028387
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209.028387
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: