Basic Information
Provider Information | |||||||||
NPI: | 1437194388 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOPPERUD | ||||||||
FirstName: | TRACEY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROEHRKASSE | ||||||||
OtherFirstName: | TRACEY | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3520 E LOUISE DR | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836426304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088880909 | ||||||||
FaxNumber: | 2088885825 | ||||||||
Practice Location | |||||||||
Address1: | 3520 E LOUISE DR | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836426304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088880909 | ||||||||
FaxNumber: | 2088885825 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2006 | ||||||||
LastUpdateDate: | 05/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | O0690 | ID | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 21910 | 01 | IA | WELLMARK, CLIVE OFFICE | OTHER |