Provider Demographics
NPI:1467433847
Name:COPPER, JOSEPH BENJAMIN JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:BENJAMIN
Last Name:COPPER
Suffix:JR
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 1:509 BARRETT RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-1433
Mailing Address - Country:US
Mailing Address - Phone:336-713-9592
Mailing Address - Fax:336-713-9576
Practice Address - Street 1:1200 N MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3006
Practice Address - Country:US
Practice Address - Phone:336-713-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100725363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ34458Medicare UPIN