Healthcare Provider Details

I. General information

NPI: 1093429367
Provider Name (Legal Business Name): MARY LINTON KOPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 09/30/2023
Certification Date: 09/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CABARRUS AVE E STE 200
CONCORD NC
28025-3781
US

IV. Provider business mailing address

101 CABARRUS AVE E STE 200
CONCORD NC
28025-3781
US

V. Phone/Fax

Practice location:
  • Phone: 803-777-7412
  • Fax:
Mailing address:
  • Phone: 855-743-2247
  • Fax: 855-857-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5018913
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: