Provider Demographics
NPI:1053366203
Name:KOCH, GINA M (DC)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:M
Last Name:KOCH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 GODFREY DR
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-7908
Mailing Address - Country:US
Mailing Address - Phone:715-256-9616
Mailing Address - Fax:715-256-9618
Practice Address - Street 1:1990 GODFREY DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-7908
Practice Address - Country:US
Practice Address - Phone:715-256-9616
Practice Address - Fax:715-256-9618
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3449-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38902900Medicaid
WI38902900Medicaid