Provider Demographics
NPI:1639481070
Name:KOPCZUK, KERRI LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:LYNN
Last Name:KOPCZUK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KERRI
Other - Middle Name:LYNN
Other - Last Name:MICHELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:609-677-7003
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:50 CRAIG RD
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-1709
Practice Address - Country:US
Practice Address - Phone:888-636-7840
Practice Address - Fax:267-479-1321
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014031363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03280100Medicaid
NYA400032456Medicare PIN