Provider Demographics
NPI:1770289621
Name:KOEPNICK, KORDELL ALAN (PA)
Entity type:Individual
Prefix:
First Name:KORDELL
Middle Name:ALAN
Last Name:KOEPNICK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11504 PAINTBRUSH LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5077
Mailing Address - Country:US
Mailing Address - Phone:208-312-7630
Mailing Address - Fax:
Practice Address - Street 1:500 S 8TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7107
Practice Address - Country:US
Practice Address - Phone:855-255-1750
Practice Address - Fax:855-255-0905
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA6140460363A00000X
ORPA219548363A00000X
IDPA-2450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant