Healthcare Provider Details

I. General information

NPI: 1982172946
Provider Name (Legal Business Name): ROOPA MUKUND PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 GATEWAY BLVD
COTTAGE GROVE OR
97424-1224
US

IV. Provider business mailing address

751 CHATEAUS DR
COPPELL TX
75019-4591
US

V. Phone/Fax

Practice location:
  • Phone: 541-942-7000
  • Fax: 541-942-7429
Mailing address:
  • Phone: 972-896-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009349
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA13220
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56233
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009790
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA216572
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number56233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: