Provider Demographics
NPI:1265174957
Name:KOPEC, KATHY ANNETTE
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:ANNETTE
Last Name:KOPEC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 WEST AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-5545
Mailing Address - Country:US
Mailing Address - Phone:845-803-9658
Mailing Address - Fax:
Practice Address - Street 1:52 BEACH RD STE 101
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6017
Practice Address - Country:US
Practice Address - Phone:203-692-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5698363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical