Provider Demographics
NPI:1336460161
Name:COPELAND, CHARLES LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:COPELAND
Suffix:
Gender:M
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 8857
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-8857
Mailing Address - Country:US
Mailing Address - Phone:260-969-6200
Mailing Address - Fax:260-969-6201
Practice Address - Street 1:7900 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-969-6200
Practice Address - Fax:260-969-6201
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000762052OtherANTHEM
IN000000762052OtherANTHEM