Provider Demographics
NPI:1558343475
Name:COPLEY, J WALTER III (PA-C)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:WALTER
Last Name:COPLEY
Suffix:III
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 1:150 DUNCAN RD
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:WV
Mailing Address - Zip Code:24924-9037
Mailing Address - Country:US
Mailing Address - Phone:304-799-7400
Mailing Address - Fax:304-846-4984
Practice Address - Street 1:150 DUNCAN RD
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:WV
Practice Address - Zip Code:24924-9037
Practice Address - Country:US
Practice Address - Phone:304-799-7400
Practice Address - Fax:304-799-2276
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00613363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVCOPA78691Medicare ID - Type UnspecifiedCMS
WVS82025Medicare UPIN