Healthcare Provider Details

I. General information

NPI: 1265054894
Provider Name (Legal Business Name): JAMES E KOCH PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SENECA ST STE 416
BUFFALO NY
14210-1351
US

IV. Provider business mailing address

397 BEACH RD
CHEEKTOWAGA NY
14225-2768
US

V. Phone/Fax

Practice location:
  • Phone: 716-289-6358
  • Fax:
Mailing address:
  • Phone: 716-289-6358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF402847-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: