Healthcare Provider Details

I. General information

NPI: 1508000357
Provider Name (Legal Business Name): MICHAEL KOROCH PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 PINE RIDGE BLVD
WAUSAU WI
54401-4102
US

IV. Provider business mailing address

333 PINE RIDGE BLVD
WAUSAU WI
54401-4102
US

V. Phone/Fax

Practice location:
  • Phone: 715-847-2121
  • Fax:
Mailing address:
  • Phone: 715-346-4570
  • Fax: 715-295-8938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4106-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number995-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: