Provider Demographics
NPI:1740843325
Name:KOPER, KOREY EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:KOREY
Middle Name:EDWARD
Last Name:KOPER
Suffix:
Gender:M
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 1:9626 GRETNA GREEN DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-5310
Mailing Address - Country:US
Mailing Address - Phone:561-676-8922
Mailing Address - Fax:
Practice Address - Street 1:2200 OSPREY BLVD
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-3308
Practice Address - Country:US
Practice Address - Phone:800-229-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant