Provider Demographics
NPI:1528216207
Name:COPELAND, DORI H (PA)
Entity Type:Individual
Prefix:
First Name:DORI
Middle Name:H
Last Name:COPELAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DORI
Other - Middle Name:H
Other - Last Name:HOLMSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-8383
Mailing Address - Fax:941-917-8930
Practice Address - Street 1:1888 HILLVIEW ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3605
Practice Address - Country:US
Practice Address - Phone:941-917-8383
Practice Address - Fax:941-917-8930
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9101417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FLPENDINGMedicare PIN