Healthcare Provider Details

I. General information

NPI: 1407222946
Provider Name (Legal Business Name): MICHELLE NICOLE KOPP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE NICOLE WALDRON PA-C

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-4001
  • Fax: 703-776-7113
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA6009
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007623
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: