Provider Demographics
NPI:1073120754
Name:KOPP, GRIFFIN (CRNA)
Entity Type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:
Last Name:KOPP
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-1525
Mailing Address - Country:US
Mailing Address - Phone:563-822-1435
Mailing Address - Fax:563-822-1436
Practice Address - Street 1:712 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1525
Practice Address - Country:US
Practice Address - Phone:563-822-1435
Practice Address - Fax:563-822-1436
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001237895163WC0200X
IAD-161938367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine