Provider Demographics
NPI:1457960502
Name:GONZALEZ COPO, TAMARA PAOLA
Entity Type:Individual
Prefix:MISS
First Name:TAMARA
Middle Name:PAOLA
Last Name:GONZALEZ COPO
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 1:330 BARCLAY AVE NE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2527
Mailing Address - Country:US
Mailing Address - Phone:616-391-8810
Mailing Address - Fax:
Practice Address - Street 1:330 BARCLAY AVE NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2527
Practice Address - Country:US
Practice Address - Phone:616-391-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351049611208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics