Provider Demographics
NPI:1942382528
Name:COPPOLA, JOSHU E (PA)
Entity Type:Individual
Prefix:
First Name:JOSHU
Middle Name:E
Last Name:COPPOLA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:611 SKYVIEW TER
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2871
Mailing Address - Country:US
Mailing Address - Phone:518-201-4003
Mailing Address - Fax:315-452-2870
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 1P
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2829
Practice Address - Fax:315-452-2870
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011563363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03316910Medicaid
NY03316910Medicaid