Provider Demographics
NPI:1518213586
Name:KOPKA, JONATHAN ROBERT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:KOPKA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 WYOMING AVE APT C
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3862
Mailing Address - Country:US
Mailing Address - Phone:570-709-1509
Mailing Address - Fax:
Practice Address - Street 1:673 WYOMING AVE APT C
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3862
Practice Address - Country:US
Practice Address - Phone:570-709-1509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN549838367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered