Healthcare Provider Details

I. General information

NPI: 1184190837
Provider Name (Legal Business Name): WILLIAM R KOOPAL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2018
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 OSLER CT STE A
ALBANY GA
31707-0205
US

IV. Provider business mailing address

204 N WESTOVER BLVD
ALBANY GA
31707-2983
US

V. Phone/Fax

Practice location:
  • Phone: 229-405-6196
  • Fax: 229-261-1334
Mailing address:
  • Phone: 229-888-6559
  • Fax: 229-436-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9568
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: