Provider Demographics
NPI:1972191575
Name:KOPPENOL, RACHEL MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:MARIE
Last Name:KOPPENOL
Suffix:
Gender:
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 1:1700 E CESAR E CHAVEZ AVE STE 2500
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2434
Mailing Address - Country:US
Mailing Address - Phone:323-306-9632
Mailing Address - Fax:323-268-6738
Practice Address - Street 1:1700 E CESAR E CHAVEZ AVE STE 2500
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2434
Practice Address - Country:US
Practice Address - Phone:323-306-9632
Practice Address - Fax:323-268-6738
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010289363A00000X
CA60720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant