Provider Demographics
NPI:1184190837
Name:KOOPAL, WILLIAM R (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:KOOPAL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:204 N WESTOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2983
Mailing Address - Country:US
Mailing Address - Phone:229-888-6559
Mailing Address - Fax:229-436-4107
Practice Address - Street 1:2403 OSLER CT STE A
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0205
Practice Address - Country:US
Practice Address - Phone:229-405-6196
Practice Address - Fax:229-261-1334
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-21
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
GA9568363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program