Healthcare Provider Details

I. General information

NPI: 1053371849
Provider Name (Legal Business Name): CARRIE L KOPALA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 GATEWAY DR
SYCAMORE IL
60178-3192
US

IV. Provider business mailing address

1850 GATEWAY DR
SYCAMORE IL
60178-3192
US

V. Phone/Fax

Practice location:
  • Phone: 815-766-9901
  • Fax: 815-758-7298
Mailing address:
  • Phone: 815-766-9901
  • Fax: 815-758-7298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002659
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: