Provider Demographics
NPI: | 1851355044 |
---|---|
Name: | COPPOLA, PETER G (P T) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | PETER |
Middle Name: | G |
Last Name: | COPPOLA |
Suffix: | |
Gender: | M |
Credentials: | P T |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3024 NE 67TH AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97213-5204 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-893-8987 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 6504 NE SISKIYOU ST |
Practice Address - Street 2: | |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97213-4572 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-893-8987 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-14 |
Last Update Date: | 2018-12-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 60861 | 225100000X |
AZ | 5305 | 2251C2600X, 2251E1200X, 2251G0304X, 2251H1200X, 2251N0400X, 2251S0007X, 2251X0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
No | 2251C2600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Cardiopulmonary |
No | 2251E1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Ergonomics |
No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
No | 2251N0400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 552910 | Medicaid | |
AZ | 205226600 | Other | US DEPT. OF LABOR |