Provider Demographics
NPI:1366512634
Name:KOPACZ, MARCIA (BSN,MSN,CNP)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:KOPACZ
Suffix:
Gender:F
Credentials:BSN,MSN,CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32270 TELEGRAPH RD
Mailing Address - Street 2:STE 240
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2456
Mailing Address - Country:US
Mailing Address - Phone:248-593-1717
Mailing Address - Fax:248-593-1711
Practice Address - Street 1:32270 TELEGRAPH RD
Practice Address - Street 2:STE 240
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2456
Practice Address - Country:US
Practice Address - Phone:248-593-1717
Practice Address - Fax:248-593-1711
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704088147163WG0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008605430OtherBCBS PROVIDER ID
P40360002Medicare PIN
MI0M84340Medicare ID - Type Unspecified