Provider Demographics
NPI:1093969735
Name:KOPRUCKI, SHAWNA (MD)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:KOPRUCKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:
Other - Last Name:BOUWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4694 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1012
Mailing Address - Country:US
Mailing Address - Phone:330-480-7655
Mailing Address - Fax:330-759-3851
Practice Address - Street 1:4694 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1012
Practice Address - Country:US
Practice Address - Phone:330-480-7655
Practice Address - Fax:330-759-3851
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD441533207Q00000X
OH35.097076207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056982Medicaid
OHH245561OtherMEDICARE PTAN