Provider Demographics
NPI:1790851301
Name:KOOPMANN, MELISSA DAWN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:DAWN
Last Name:KOOPMANN
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 1:2655 COUNTY HIGHWAY I
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-1423
Mailing Address - Country:US
Mailing Address - Phone:715-726-4200
Mailing Address - Fax:715-726-4173
Practice Address - Street 1:2655 COUNTY HIGHWAY I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-1423
Practice Address - Country:US
Practice Address - Phone:715-726-4200
Practice Address - Fax:715-726-4173
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL385-001225363A00000X
WI5638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ67359Medicare UPIN
ILK26819Medicare ID - Type Unspecified