Healthcare Provider Details

I. General information

NPI: 1376699181
Provider Name (Legal Business Name): JOHN PAUL KOPCHAK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 CASTRO ST 423
SAN FRANCISCO CA
94114-1010
US

IV. Provider business mailing address

179 GREVILLIA DR
PETALUMA CA
94952-6111
US

V. Phone/Fax

Practice location:
  • Phone: 415-551-9758
  • Fax: 415-437-5434
Mailing address:
  • Phone: 510-495-4585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA12753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: