Provider Demographics
NPI:1932336195
Name:COPPER, CRYSTAL A (RPA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:COPPER
Suffix:
Gender:F
Credentials:RPA-C
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9800
Mailing Address - Fax:239-343-9848
Practice Address - Street 1:4771 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1317
Practice Address - Country:US
Practice Address - Phone:239-343-9800
Practice Address - Fax:239-343-9848
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013114363A00000X
FLPA9111856363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115449500Medicaid