Healthcare Provider Details

I. General information

NPI: 1790851301
Provider Name (Legal Business Name): MELISSA DAWN KOOPMANN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 COUNTY HIGHWAY I
CHIPPEWA FALLS WI
54729-1423
US

IV. Provider business mailing address

2655 COUNTY HIGHWAY I
CHIPPEWA FALLS WI
54729-1423
US

V. Phone/Fax

Practice location:
  • Phone: 715-726-4200
  • Fax: 715-726-4173
Mailing address:
  • Phone: 715-726-4200
  • Fax: 715-726-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number385-001225
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5638
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: