Provider Demographics
NPI:1053371849
Name:KOPALA, CARRIE L (PA-C)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:KOPALA
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 1:1850 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3192
Mailing Address - Country:US
Mailing Address - Phone:815-766-9901
Mailing Address - Fax:815-758-7298
Practice Address - Street 1:1850 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-766-9901
Practice Address - Fax:815-758-7298
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q61398Medicare UPIN
ILP00923847Medicare PIN
ILT01216Medicare PIN
ILT01215Medicare PIN
K24463Medicare ID - Type Unspecified