Provider Demographics
NPI:1881266716
Name:KUPPERS, JOHANN (MD)
Entity type:Individual
Prefix:
First Name:JOHANN
Middle Name:
Last Name:KUPPERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 14TH AVE SE
Mailing Address - Street 2:APT A7
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503
Mailing Address - Country:US
Mailing Address - Phone:626-838-8251
Mailing Address - Fax:
Practice Address - Street 1:525 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506
Practice Address - Country:US
Practice Address - Phone:360-493-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML61164276207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine