=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750162780
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS BRENT KOCH AGPCNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2023
-----------------------------------------------------
Last Update Date | 11/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 E HURON ST STE 1101
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-741-8554
-----------------------------------------------------
Fax | 312-216-1779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 E HURON ST STE 1101
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-741-8554
-----------------------------------------------------
Fax | 312-216-1779
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 209.028387
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 209.028387
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------