Healthcare Provider Details

I. General information

NPI: 1780858951
Provider Name (Legal Business Name): CHRISTOPHER KOCH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 TECHNOLOGY DRIVE SUITE 104
EAST SETAUKET NY
11733
US

IV. Provider business mailing address

8 TECHNOLOGY DRIVE SUITE 104
EAST SETAUKET NY
11733
US

V. Phone/Fax

Practice location:
  • Phone: 516-704-7447
  • Fax:
Mailing address:
  • Phone: 516-704-7447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012427
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: