Healthcare Provider Details

I. General information

NPI: 1922401066
Provider Name (Legal Business Name): JASON R KOCH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 MOUNT RUSHMORE RD
RAPID CITY SD
57702
US

IV. Provider business mailing address

7220 MOUNT RUSHMORE RD
RAPID CITY SD
57702-8754
US

V. Phone/Fax

Practice location:
  • Phone: 605-341-1414
  • Fax: 605-341-7062
Mailing address:
  • Phone: 605-737-9144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1144
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: