Basic Information
| Provider Information | |||||||||
| NPI: | 1619919503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VOPAT | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | ATTEN CHRISTIE MSS | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034674155 | ||||||||
| FaxNumber: | 3034674156 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 JACKSON BLVD | ||||||||
| Address2: | 100 | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577024386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057552273 | ||||||||
| FaxNumber: | 6057553902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 393 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0874 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970004830 | 01 | MEDICARE RAILROAD | OTHER | 7393002 | 05 | CO | MEDICAID |