Healthcare Provider Details

I. General information

NPI: 1609146786
Provider Name (Legal Business Name): ROBERT D COPIC R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 BROADWAY AVE N
BRAHAM MN
55006-4711
US

IV. Provider business mailing address

11335 246TH CIR
ZIMMERMAN MN
55398-4663
US

V. Phone/Fax

Practice location:
  • Phone: 320-396-3333
  • Fax: 320-396-3363
Mailing address:
  • Phone: 763-856-0121
  • Fax: 320-396-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number169978-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: