Healthcare Provider Details

I. General information

NPI: 1629729876
Provider Name (Legal Business Name): MICHAEL KOPANIASZ APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

5139 OLDE RIDGE RD
SYLVANIA OH
43560-1882
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 419-944-3920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704268626
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: