Healthcare Provider Details

I. General information

NPI: 1750460267
Provider Name (Legal Business Name): EVON KOPITAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AVENUE AND ROOSEVELT ROAD ATTN: EYE CLINIC A116L
HINES IL
60141
US

IV. Provider business mailing address

875 E 22ND ST APT 412
LOMBARD IL
60148-5026
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-2061
  • Fax:
Mailing address:
  • Phone: 630-953-9053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: