Provider Demographics
NPI:1154392819
Name:KOPECKY, EDWARD L (CRNA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:KOPECKY
Suffix:
Gender:M
Credentials:CRNA
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-242-7308
Mailing Address - Fax:702-240-8790
Practice Address - Street 1:2450 W CHARLESTON
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-877-8660
Practice Address - Fax:702-258-1322
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCRNA 00027367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2402003Medicaid
NVV$$$$$$$$$Medicare PIN
S01170Medicare UPIN