Provider Demographics
NPI:1215041405
Name:COPPALA, ERIC M (CRNA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:M
Last Name:COPPALA
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 1:1304 OAK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3111
Mailing Address - Country:US
Mailing Address - Phone:321-723-4723
Mailing Address - Fax:321-727-1448
Practice Address - Street 1:1304 OAK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3111
Practice Address - Country:US
Practice Address - Phone:321-723-4723
Practice Address - Fax:321-727-1448
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9216799367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3645OtherBCBSFL
FLP00216595OtherRRMCR
FLG3645ZMedicare ID - Type Unspecified