Healthcare Provider Details

I. General information

NPI: 1689625816
Provider Name (Legal Business Name): BETTIE H COPLAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST
PHOENIX AZ
85006-2848
US

IV. Provider business mailing address

300 W CLARENDON AVE STE 200
PHOENIX AZ
85013-3422
US

V. Phone/Fax

Practice location:
  • Phone: 602-254-5321
  • Fax: 602-254-6582
Mailing address:
  • Phone: 602-254-5321
  • Fax: 602-254-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2293
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: