Provider Demographics
NPI:1033206073
Name:COPELAND, WANDA O (FNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:O
Last Name:COPELAND
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-8104
Mailing Address - Country:US
Mailing Address - Phone:803-874-2006
Mailing Address - Fax:803-874-1998
Practice Address - Street 1:558 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SAINT MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-8104
Practice Address - Country:US
Practice Address - Phone:803-874-2006
Practice Address - Fax:803-874-1998
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCR48888Medicare UPIN
SCGP3748Medicare ID - Type Unspecified
SC5677Medicare ID - Type UnspecifiedMEDICARE GROUP#