Provider Demographics
NPI:1598761082
Name:KOOP, CHRISTINE POWERS (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:POWERS
Last Name:KOOP
Suffix:
Gender:F
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6303
Mailing Address - Fax:
Practice Address - Street 1:2104 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5941
Practice Address - Country:US
Practice Address - Phone:864-676-1072
Practice Address - Fax:864-676-0729
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1888363A00000X
IL085001153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1573PAMedicaid
IL085001153Medicaid
IL540880Medicare PIN
IL085001153Medicaid
SCSC04847951Medicare PIN