Provider Demographics
NPI:1497867907
Name:KOEPP, PETER CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:CHRISTOPHER
Last Name:KOEPP
Suffix:
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 1:2817 REILLY ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-7324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7324
Practice Address - Country:US
Practice Address - Phone:910-396-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05201363AS0400X
NC0010-02309363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y0987OtherBLUE CROSS
TX186438101Medicaid
TX186438101Medicaid
TX8Y0987OtherBLUE CROSS