Provider Demographics
NPI:1376699181
Name:KOPCHAK, JOHN PAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PAUL
Last Name:KOPCHAK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:179 GREVILLIA DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-6111
Mailing Address - Country:US
Mailing Address - Phone:510-495-4585
Mailing Address - Fax:
Practice Address - Street 1:45 CASTRO ST
Practice Address - Street 2:423
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1010
Practice Address - Country:US
Practice Address - Phone:415-551-9758
Practice Address - Fax:415-437-5434
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12753363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical