Provider Demographics
NPI:1649334863
Name:COPPOCK, LARRY RAY (CCP LP RN)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:RAY
Last Name:COPPOCK
Suffix:
Gender:M
Credentials:CCP LP RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12815
Mailing Address - Street 2:3601 N MAY AVENUE SUITE C
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73157-2815
Mailing Address - Country:US
Mailing Address - Phone:405-604-5613
Mailing Address - Fax:405-601-3750
Practice Address - Street 1:3601 N MAY AVE
Practice Address - Street 2:SUITE C
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6641
Practice Address - Country:US
Practice Address - Phone:405-604-5613
Practice Address - Fax:405-601-3750
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLP7247200000X, 242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
731213482002OtherBCBS
5993501OtherAETNA