MEDICARE: MR. BRUCE EVAN KOCH CRNA MSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	AP30007302	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RN00163452	OTHER	WA	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	AP30007302	OTHER	WA	STATE LICENSE

General Provider Information

NPI Number	:	1336128180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRUCE EVAN KOCH CRNA MSN

Provider Business Mailing Address
First Line	:	5633 N LIDGERWOOD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208
Country	:	US
Telephone Number	:	509-482-0111
Fax Number	:

Provider Business Practice Location Address
First Line	:	5633 N LIDGERWOOD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208
Country	:	US
Telephone Number	:	509-482-0111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	05/29/2009

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