Provider Demographics
NPI:1033510508
Name:KOPPAL, THERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KOPPAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:480-418-3323
Practice Address - Street 1:2940 E BANNER GATEWAY DR STE 200-250
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:602-548-5444
Practice Address - Fax:602-772-3801
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5748363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical