Provider Demographics
NPI:1447240437
Name:COPELAND, KATIE E (MD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:E
Last Name:COPELAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:3277 E LOUISE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9351
Practice Address - Country:US
Practice Address - Phone:208-468-5930
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8753208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806551600Medicaid
ID370022701OtherRR MEDICARE
ID53199OtherBLUE CROSS
ID000010142776OtherBLUE SHIELD
ID806567400OtherHEALTHY CONNECTIONS
H17850Medicare UPIN
ID806551600Medicaid