Healthcare Provider Details

I. General information

NPI: 1356326631
Provider Name (Legal Business Name): CHARLES L. KOCK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHARLES LEWIS KOCK PHYSICIAN, ASSISTANT

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DENNING DR
HOUMA LA
70360-3977
US

IV. Provider business mailing address

201 DENNING DR.
HOUMA LA
70360
US

V. Phone/Fax

Practice location:
  • Phone: 985-855-4829
  • Fax:
Mailing address:
  • Phone: 985-855-4829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberA10076
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: