Provider Demographics
NPI:1346669249
Name:KOPPELMAN, WAYNE THOMAS (LMP)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:THOMAS
Last Name:KOPPELMAN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8747 PHINNEY AVE N
Mailing Address - Street 2:UNIT 1
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3764
Mailing Address - Country:US
Mailing Address - Phone:818-270-8715
Mailing Address - Fax:
Practice Address - Street 1:8747 PHINNEY AVE N
Practice Address - Street 2:UNIT 1
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-3764
Practice Address - Country:US
Practice Address - Phone:818-270-8715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60452595225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist