Healthcare Provider Details

I. General information

NPI: 1730859992
Provider Name (Legal Business Name): ZACHARY KOPECKY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 E FLORENCE BLVD
CASA GRANDE AZ
85122-4782
US

IV. Provider business mailing address

213 S IRONWOOD ST
GILBERT AZ
85296-1629
US

V. Phone/Fax

Practice location:
  • Phone: 520-374-8915
  • Fax:
Mailing address:
  • Phone: 480-389-7097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8613
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: