MEDICARE: HEATHER KOPONEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	383	AK

General Provider Information

NPI Number	:	1023008042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER KOPONEN PA-C

Provider Business Mailing Address
First Line	:	1408 19TH AVE
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99701-5903
Country	:	US
Telephone Number	:	907-451-6682
Fax Number	:	907-459-3912

Provider Business Practice Location Address
First Line	:	1408 19TH AVE
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99701-5903
Country	:	US
Telephone Number	:	907-451-6682
Fax Number	:	907-459-3912

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	07/08/2007

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Directions to “ HEATHER KOPONEN PA-C” Practice Location

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