Provider Demographics
NPI:1043883259
Name:KOOPMAN, REBECCA SUE (PA-C)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:SUE
Last Name:KOOPMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:BECCA
Other - Middle Name:SUE
Other - Last Name:KOOPMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1901 CAMPUS PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2308
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:
Practice Address - Street 1:705 FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-6778
Practice Address - Country:US
Practice Address - Phone:812-752-0165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-24
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114971363A00000X
363A00000X
IN10004445A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant