Provider Demographics
NPI:1295971836
Name:COPELAND, TAMARA LEE (PA-C)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:LEE
Last Name:COPELAND
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 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:340 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2421
Practice Address - Country:US
Practice Address - Phone:931-783-5353
Practice Address - Fax:931-783-4994
Is Sole Proprietor?:No
Enumeration Date:2009-01-04
Last Update Date:2023-03-07
Deactivation Date:2019-09-19
Deactivation Code:
Reactivation Date:2019-09-26
Provider Licenses
StateLicense IDTaxonomies
TN1678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527896Medicaid
TN1527896Medicaid