Healthcare Provider Details

I. General information

NPI: 1891374260
Provider Name (Legal Business Name): NICHOLAS BURKE KOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 BLUE RIDGE RD STE 301
RALEIGH NC
27612-8036
US

IV. Provider business mailing address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5871
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-2930
  • Fax: 919-784-2929
Mailing address:
  • Phone: 704-446-9243
  • Fax: 704-446-9120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2026-05086
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: