Provider Demographics
NPI:1144885013
Name:LOSCH, DEVON LEE (PA-C)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:LEE
Last Name:LOSCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEVON
Other - Middle Name:LEE
Other - Last Name:PERKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:200 HIGH PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4810
Mailing Address - Country:US
Mailing Address - Phone:574-364-2888
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:574-364-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002950A363A00000X
MSPA00575363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03406312Medicaid
IN300038776Medicaid