Healthcare Provider Details

I. General information

NPI: 1669225363
Provider Name (Legal Business Name): SHELBY JAYE KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 E 32ND ST
TACOMA WA
98404-4922
US

IV. Provider business mailing address

215 H ST NE
EPHRATA WA
98823-1731
US

V. Phone/Fax

Practice location:
  • Phone: 253-593-0232
  • Fax: 253-441-2695
Mailing address:
  • Phone: 509-398-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML61550008
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: