Provider Demographics
NPI:1982847174
Name:COPELAND, WENDY PALEN (PA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:PALEN
Last Name:COPELAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:MICHELLE
Other - Last Name:PALEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2412 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2567
Mailing Address - Country:US
Mailing Address - Phone:229-244-1400
Mailing Address - Fax:229-244-5512
Practice Address - Street 1:2412 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2567
Practice Address - Country:US
Practice Address - Phone:229-244-1400
Practice Address - Fax:229-244-5512
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005565OtherLICENSE
GA005565OtherLICENSE