Provider Demographics
NPI:1962998856
Name:COPELAND, ILEY SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:ILEY
Middle Name:SCOTT
Last Name:COPELAND
Suffix:
Gender:M
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-329-5781
Mailing Address - Fax:
Practice Address - Street 1:900 N ORANGE ST STE 304
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2951
Practice Address - Country:US
Practice Address - Phone:406-329-5781
Practice Address - Fax:406-327-3331
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60870353363A00000X
MTMED-PAC-LIC-100093363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant