Healthcare Provider Details

I. General information

NPI: 1770092967
Provider Name (Legal Business Name): RYAN TAYLOR KOCH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 1ST ST
MINEOLA NY
11501-3957
US

IV. Provider business mailing address

37 OAKLEDGE DR
EAST NORTHPORT NY
11731-3720
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-0333
  • Fax:
Mailing address:
  • Phone: 631-697-7119
  • Fax: 631-697-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: