Provider Demographics
NPI:1912447343
Name:COPPOLA, VICTORIA (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:COPPOLA
Suffix:
Gender:F
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 1:12 LANCELOT LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1913
Mailing Address - Country:US
Mailing Address - Phone:856-206-2440
Mailing Address - Fax:
Practice Address - Street 1:40 BEY LEA RD
Practice Address - Street 2:SUITE B203
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-2900
Practice Address - Country:US
Practice Address - Phone:732-341-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-05
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00426200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant