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General NPI Number Information
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NPI Number | 1497221089
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Entity Type | Individual
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Provider Name | ALYSSA NICOLE KOOPAL PA
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Gender | Female
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Dates
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Enumeration Date | 10/22/2018
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Last Update Date | 10/24/2022
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Provider Practice Location Address
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Address Line | 1712A E BROAD AVE
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City | ALBANY
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State | GA
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Zip | 31705-2611
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Country | US
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Telephone | 229-639-3100
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Fax |
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Provider Business Mailing Address
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Address Line | 142 PLANTATION DR
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City | LEESBURG
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State | GA
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Zip | 31763-4284
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Country | US
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Telephone | 310-650-2839
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 9443
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License Number State | GA
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