Provider Demographics
NPI:1720057110
Name:KOPERNA, LISA RENEE (PT, DPT, SCS, ATC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:KOPERNA
Suffix:
Gender:F
Credentials:PT, DPT, SCS, ATC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RENEE
Other - Last Name:JESBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1015 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23529-0001
Mailing Address - Country:US
Mailing Address - Phone:757-683-4228
Mailing Address - Fax:757-683-7050
Practice Address - Street 1:1015 W 47TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23529-0001
Practice Address - Country:US
Practice Address - Phone:757-683-4228
Practice Address - Fax:757-683-7050
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004592225100000X, 2251S0007X
VA01260006192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA496680Medicare ID - Type Unspecified