Healthcare Provider Details

I. General information

NPI: 1740843325
Provider Name (Legal Business Name): KOREY EDWARD KOPER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 OSPREY BLVD
BARTOW FL
33830-3308
US

IV. Provider business mailing address

9626 GRETNA GREEN DR
TAMPA FL
33626-5310
US

V. Phone/Fax

Practice location:
  • Phone: 800-229-2273
  • Fax:
Mailing address:
  • Phone: 561-676-8922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111863
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: