Provider Demographics
NPI:1417423336
Name:KOPP, TANYA M
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:KOPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10546 MAPLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103-9512
Mailing Address - Country:US
Mailing Address - Phone:716-251-8568
Mailing Address - Fax:
Practice Address - Street 1:10546 MAPLE RIDGE RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-9512
Practice Address - Country:US
Practice Address - Phone:716-251-8568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320120164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse