Provider Demographics
NPI:1669225363
Name:KOCH, SHELBY JAYE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:JAYE
Last Name:KOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 H ST NE
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1731
Mailing Address - Country:US
Mailing Address - Phone:509-398-6979
Mailing Address - Fax:
Practice Address - Street 1:2209 E 32ND ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-4922
Practice Address - Country:US
Practice Address - Phone:253-593-0232
Practice Address - Fax:253-441-2695
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML61550008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine