Healthcare Provider Details

I. General information

NPI: 1205074721
Provider Name (Legal Business Name): KRISTEN MARIE KOCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 HIGHLAND AVE
SALEM MA
01970-2714
US

IV. Provider business mailing address

459 APPLETON ST
ARLINGTON MA
02476-7050
US

V. Phone/Fax

Practice location:
  • Phone: 978-354-4173
  • Fax:
Mailing address:
  • Phone: 413-374-1667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAP2633
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: